A spectrum disorder with varied symptoms and no clinically agreed criteria for classifying its severity - just how do you go about underwriting autism? Kevin Edwards investigates
Autism is still a relatively unknown condition, despite the intervening 60 years of medical research into the disability. It is often referred to as a 'spectrum disorder' due to the wide and varied severity of problems the individual may experience. Symptoms can range from mild, hardly noticeable behavioural traits through to quite severe mental retardation, which will require the individual to live in a closely supervised environment.
The earliest behavioural traits of the condition can be seen from age two to three. There is no specific test for the condition, which can make diagnosing autism very problematic. Behavioural problems that can be secondary to other conditions - such as hearing loss, speech problems and mental retardation - have to be excluded in the first instance. The final diagnosis has to be made through observation and evaluation of the child's behaviour against a list of recognised autistic characteristics.
There are three areas of impairment commonly associated with autism - social interaction, social communication and imagination.
Generally, these impairments often manifest themselves as:
• Little or no speech
• Delayed development of speech
• Poor interaction
• Lack of eye contact
• Absence of facial expression and body language
• A preference for being alone
• Lack of imaginative play
• Aggressive behaviour
• Obsessive routines
• No fear or awareness of danger
• Repetition of words and phrases
• Hand flapping
• Toe walking
This list is far from exhaustive and the full range of indicative behaviours is long and varied.
There are a number of disorders that display some or many of the classic signs of autism and they are often referred to as 'autistic spectrum disorders'. The most prevalent of these is Aspergers Syndrome (AS). This condition is characterised by the autistic traits of poor understanding of communication, social interaction and abstract thinking. However, unlike an autistic individual, an AS sufferer has fewer language and learning difficulties and will actively seek social interaction rather than withdraw from it. They are often of average or above average intelligence.
Other conditions that show autistic behaviour are Landau-Kleffner Syndrome, Rett Syndrome, Williams Syndrome and Fragile X Syndrome. These conditions vary in their severity of disability and, from an underwriter's point of view, are dealt with separately from autism.
So what causes autism? Unfortunately, the cause is as yet unknown. However, research is showing that genetic factors are important. The high prevalence of identical twins, compared to non-identical twins, both having autism would appear to support this.
There may also be a connection with a number of conditions that can affect brain development before, during or very soon after childbirth - this may be a trigger for autism.
There is also disputed evidence that there may be a link to the mumps, measles and rubella vaccine (MMR). This matter has received extensive coverage in the media since the original 1998 article highlighting a possible link. However, the overwhelming medical opinion and subsequent research believes the MMR vaccine to be safe.
There is no recognised medication for autism. In some cases Ritalin - a drug used in the treatment of attention deficit hyperactivity disorder - may show favourable results but in the main, individually tailored specialist education and therapies are the norm. There is no cure.
By far the most common complication of the condition is mental retardation. Up to 80% of individuals with autism have some degree of mental retardation. Of these, approximately 20% are classified as being severely retarded, with IQ of less than 35. However, a small proportion (10%) have average or above average intelligence.
There is an increased frequency of seizures and epilepsy in autistic individuals and around a third go on to develop the disorder. This often affects those with more severe mental retardation.
Some people will have associated brain function disorders such as Down's Syndrome and Tourette's Syndrome.
Autism is a very complex disease and one that varies hugely from one individual to another. The displayed behaviours mirror many existing mental and behavioural disorders and it is this fact that makes the condition such a difficult one to pin down. However, awareness is growing, and sufferers are receiving the specialist treatment at an ever-earlier age. This is key to enabling the person to maximise their skills and potential in their adult social and working lives.
Kevin Edwards is a life and disability underwriter at Scottish Equitable Protect
Classifying the risk is the most difficult aspect of underwriting autism. As mentioned, it is a spectrum disorder with wide and varied communication and behavioural symptoms and degrees of severity. As such, there are no clinically agreed criteria used in classifying the severity of the condition.
The main deficit in autism is one of mental ability. When underwriting the disability, the degree of mental retardation is assessed first.
Using IQ as a starting point, we would attempt to classify the applicant as either:
• Higher functioning autism - IQ above 70. Minimal, if any, impairment in sensory-motor ability and good language skills. Able to live independently.
• Mild - IQ 50 to 70. Minimal impairment and has acquired basic literacy and numeracy skills. May need assistance if stressed and may be able to live alone or with some supervision.
• Moderate - IQ 35-49. Has acquired some communication skills with training and can attend to personal care. Some early school academic achievement. Significant social impairment but may be able to perform unskilled or semi-skilled labour under supervision.
• Severe - IQ 20 to 34. Poor motor development and little, if any, speech or communication skills. Cannot live independently.
• Profound - IQ below 20. Requires living in a closely supervised setting.
We would next look to determine if there is a history of any associated disorders such as depression or anxiety, obsessive-compulsive disorders or any previous incidence of seizures and epilepsy. The extent of any dependence on other people for their day-to-day living is also key.
Higher functioning autism offers the most favourable prognosis and as such can attract ordinary rates in cases without any associated epilepsy or behavioural disorders. If a secondary disorder is present, a premium loading can be expected.
Mild to moderate autism may attract ordinary rates or a minimal loading if there are no secondary or associated conditions. With epilepsy and behavioural problems present, a premium loading will be applied taking into account the severity of these secondary issues.
Severe or profound autism would normally be declined.
Disability benefits will only be considered for a higher function autistic individual. Those more severely affected by the condition are more likely to be unable to fully care for themselves and therefore require supervision. Waiver of premium and total, and permanent disability benefit could not be considered in these cases.
• An estimated 535,000 people have autism in the UK. That is one in every 2,000
• Boys are four times more likely to develop the condition than girls
• Siblings of a child with the condition are 75 times more likely to develop symptoms
• 21% of children with an autistic spectrum disorder have been excluded from school at some point
• 75% of people with autism have an associated learning disability.
The news that the ABI and British Medical Association (BMA) agreement on GP report (GPR) fees has broken down will usher in a period of uncertainty.
Lack of innovation investment in the UK insurance market has been highlighted by recognition of RGA's work in the US.
Protection business in 2012 and 2013 will be affected by events this year and some fundamental changes to the way customers policies are priced into the next. Richard Verdin explains.
Employee assistance programmes are in the spotlight due to a schizophrenic approach by government. But as Sue Weir points out, they are backed by solid research.
How will people buy insurance in future? Greg Becker visits the US for developments in online distribution.