Research in Autism Spectrum Disorders 4 (2010) 156–167

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

Journal homepage: http://ees.elsevier.com/RASD/default.asp

Review

A review of the prevalence of Autism Spectrum Disorder in Asia

Xiang Sun a,*, Carrie Allison b
a
Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, United Kingdom
b
Department of Psychology, Douglas House, 18b Trumpington Road,CB2 8AH, University of Cambridge, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Electronic databases and bibliographies were searched for English language articles on the
Received 27 June 2009 prevalence of Autism Spectrum Disorder in Asia over time to estimate prevalence. The
Received in revised form 30 September 2009 overall reported prevalence of ASD in recent studies was higher than the previously
Accepted 3 October 2009
reported in Asia. The average prevalence of ASD before 1980 was around 1.9/10,000 while
it was 14.8/10,000 from 1980 to present. The median prevalence of ASD among 2–6-year-
Keywords:
old children who are reported in China from 2000 upwards was 10.3/10,000. ASD is
Autism Spectrum Disorder
probably more common in Asia than previously thought.
Prevalence
Screening ß 2009 Elsevier Ltd. All rights reserved.
Diagnosis
Asia

Contents

1. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
2.1. Search results and description of characteristics of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
2.2. Study design (Table 2) . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
2.2.1. Screening sources . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
2.2.2. Screening instruments. . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
2.3. Prevalence estimates for ASD in Asia . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
2.4. Prevalence estimates after 1980 . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
2.5. Time trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
2.6. Geographical areas . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
2.7. Birth variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
2.8. Ethnic background and migration . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
2.9. Educational level . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
2.10. Socioeconomic status . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
3.1. Summary of findings . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
3.2. Critique of methods . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
4. Conclusions and recommendations. . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

* Corresponding author.
E-mail address: xs227@medschl.cam.ac.uk (X. Sun).

1750-9467/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2009.10.003
 X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167 157

Autism Spectrum Disorder (ASD) is used to describe a group of childhood neuro-developmental disorders whose onset is
usually before 3 years old (Charman et al., 2008; Williams, 2003). ASD is characterized by impairments in social interaction
and communication and the presence of restrictive and stereotyped patterns of behaviours, interests, and activities
(Charman et al., 2008).
Over the past two decades, researchers and practitioners in medicine, public health, education, and social work have
shown an increasing concern about the prevalence of ASD. Since the first epidemiological study of autism in England in 1966
(Lotter, 1966), many surveys have been conducted reporting widely varying prevalence estimates. ASD was initially
considered to be rare with prevalence estimated to be around 2/10,000 children in the 1970s (Kawamura, Takahashi, & Ishii,
2008). However, this view began to change towards the end of last century (Gillberg & Wing, 1999). The most recent
prevalence estimate of ASD in the UK is reported to be 116.1/10,000 children (Baird et al., 2006). This increase might be due
to several factors (Tanoue, Oda, Asano, & Kawashima, 1988): changes in the application of epidemiological study methods;
the use of different screening tools; changes in diagnostic criteria. Additionally, an improvement in living conditions as well
increased awareness among both the general population and health professionals may have contributed to the perceived
increase in the prevalence of ASD. It is also possible that there has been a true increase (Tanoue et al., 1988).
Although ASD is commonly recognized in Europe and America, it is a relatively new concept in the Eastern world. Since
most studies of ASD have been carried out in Western countries, the prevalence of ASD in Asia is less known. As Asia
represents a large percentage of the world population, there is a need to explore the epidemiology of ASD in Asia to find out if
there are differences in the prevalence of ASD across different cultures. Therefore, the purpose of this review is to describe
the epidemiology and estimate the prevalence of ASD in Asia.

1. Method

Three databases were used in this review: Pubmed (1980 to November 2008), Web of Knowledge (1980 to November
2008) and the Chinese Knowledge database (1998 to November 2008). In addition, bibliographies of previous reviews were
also searched to identify published prevalence studies. There were three stages in the literature search. In stage 1, the search
terms included ‘‘Autism Spectrum Disorders’’ or ‘‘Autism’’ or ‘‘Autism disorder’’ plus ‘‘Prevalence’’. In stage 2, further search
was conducted for each country in Asia one by one with the search terms listed above. In stage 3, all the papers identified
after the first two stages were examined by inclusion criteria. Papers were selected if it was an original epidemiological study
published in English but not an aetiological study. It focused on ASD with clear description of screening methods and
diagnostic criteria used in case identification but not Asperger’s syndrome. The sample size was more than 2000 and
individuals were not older than 18 in the study. After full examination, data were extracted from each study including first
author, year of publication, country, region and area of study, screening strategy and information source, diagnostic criteria
and strategy, age of diagnosis, size of population, reported prevalence estimate of ASD. If manuscripts contained several
analyses, data were extracted only on those analyses that met the inclusion criteria.

2. Results

2.1. Search results and description of characteristics of studies

Twenty-six studies were identified on the prevalence of ASD, including 17 original articles and 9 studies from literature
reviews. During the search, three studies were identified about multicultural settings (such as Asian immigrants in other
countries). However, none of these described the differences in prevalence estimates between Asian immigrants and local
(native) populations.
The characteristics of the 26 studies and a summary of the main findings are presented in Table 1. These studies covered
six countries which conducted research on the prevalence of ASD from 1972 to 2008 in Asia, including China (7), Japan (13),
Israel (2), Iran (1), Taiwan (1) and Indonesia (1). Two thirds of studies investigated urban (67%) prevalence of ASD and the
remaining studies were carried out in both urban and rural contexts. Three studies (Chen, Liu, Su, Huang, & Lin, 2007; Kamer
et al., 2004; Zhang, Sui, & Wand, 2008) addressed the differences between rural and urban populations. The age range among
children was from 0 to 18 years old. Eleven studies focused on the children who were less than or equal to 6 years old, 12
studies covered children 6–12 years old and 6 studies investigated children between 12 and 18 years old. The male to female
ratio ranged from 1.3:1 (Ghanizadeh, 2008) to 6.5:1 (Tao, 1987). There was a considerable variation in the size of the
populations among selected studies (range: 2000–1,113,900), with a median size of 25,521 in Chinese studies and 597,003 in
Japanese studies.

2.2. Study design (Table 2)

2.2.1. Screening sources

Most studies after 1980 used a two-stage approach to case ascertainment. The first stage was screening which usually
included sending a letter or questionnaire-based screening tool to schools and health centres to identify potential cases of
ASD. The screening tools used in Asia were heterogeneous and are shown in Table 3. There were three main screening
settings in Asia: seven Chinese studies (Guo, 2009; Lou, Lin, & Chen, 2000; Ren, Duan, & Xu, 2003; Wang, Zai, & Zhen, 2002;
158 X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167

Table 1
Epidemiological studies of ASD in Asia (1971–2008).

No. Year of publication First author Country Region Area

a
1 1971 Yamazaki Japan – –
2a 1971 Haga Miyamoto Japan – –
3a 1971 Nakai Japan – –
4a 1971 Tanino Japan – –
5a 1980 Hoshino Japan Fukushima Ken Mixed
6a 1983 Ishii and Takahashi Japan – Urban
7a 1987 Maisuishi Japan Kurume City Urban
8 1987 Taokuo Tai China Nanjing City Urban
9 1988 Tanoue Japan Ibaraki Urban
10 1989 Sugiyama Japan Nagoya Urban
11a 1992 Ohtaki Japan Chikugo City Mixed
12a 1992 Wignyosumarto Indonesia Yogyakarita –
13 1996 Honda Japan Yokohama Urban
14 2000 Weiwu Luo China Fujian (Province) Mixed
15 2001 Davidovitch Israel Haifa Mixed
16 2002 Weihu Luo China Changzhou city Urban
17 2003 Weihua Wang China Jiangsu (Province) Mixed
18 2003 Luzhong Ren China Tongling City Urban
19 2004 A. Kamer Israel Israel Mixed
20 2004 Rong Guo China Tianjing City Urban
21 2005 Honda Japan Yokohama Urban
22 2007 Almad Ghanizadeh Iran Shiraz Urban
23 2007 Shuguang Yang China Zuiyi city Urban
24 2008 Feng Zhang China Wuxi city Urban
25 2008 Kawamura Japan Toyota Urban
26 2008 Chuanyu Chen Taiwan Taiwan Mixed

(–) No details given from previous reviews and not possible to gain the original papers.
a
Studies cited in previous reviews.

Wang, Huo, & Li, 2003; Yang, Hu, & Han, 2007; Zhang et al., 2008) conducted by medical institutes who randomly chose their
samples from the local population; five recent surveys (Honda, Shimizu, Misumi, Niimi, & Ohashi, 1996; Honda, Shimizu,
Imai, & Nitto, 2005; Kawamura et al., 2008; Sugiyama and Abe, 1989; Tanoue et al., 1988) from Japan relied on a general
health examination conducted by local health centres which assumed they had covered the whole local population; six
surveys by educational institutes (Ghanizadeh, 2008; Guo, 2009; Hughes, 2008; Ishii & Takahashi, 1983; Kawamura et al.,
2008; Matsuishi et al., 1987; Ohtaki et al., 1992) including children in special and mainstream schools.

2.2.2. Screening instruments

Eight screening instruments were used among studies. In Japan, two studies (Blaxill, 2004; Hoshino, Kumashiro, Yashima,
Tachibana, & Watanabe, 1982; Ishii & Takahashi, 1983) used questionnaires or letters. After the 1970s, five studies (Honda
et al., 1996, 2005; Kawamura et al., 2008; Sugiyama and Abe, 1989; Tanoue et al., 1988) used an 18-month health checklist
(HC-18). The studies using the HC-18 employed a ‘‘fail-safe’’ system (Fig. 1) to capture the false negative cases (Honda et al.,
2005) and can be considered to have a relatively complete method of case ascertainment at this stage. As for China, five
studies used the Chinese Autism Behaviour Scale (CABS), 2 used the Autism Behaviour Checklist (ABC), and others used an
existing database and the Checklist for Autism in Toddlers (CHAT). The local Bryson’s Screening Scale was used in Indonesia
while the study in Iran (Ghanizadeh, 2008) used the Childhood Symptom Inventory-4 (CSI-4).

2.3. Prevalence estimates for ASD in Asia

Since study designs and assessment methodologies were heterogeneous among the 26 studies, it is difficult to compare
their results and provide estimates of prevalence (Table 4). However, studies conducted in China or Japan appear to have
relatively similar methodology within country. It is therefore reasonable to estimate prevalence for these two countries
separately (Tables 5 and 6).
The prevalence of ASD in these studies selected in this review ranged from 0.32/10,000 (Tao, 1987) to 250/10,000 (Ren
et al., 2003). The Chinese study in Tongling (Ren et al., 2003) city (250/10,000) and the Iranian (Yang et al., 2007) study (190/
10,000) only provided screening results (based on cut-points) without any further diagnostic procedure. Another Chinese
study in Nanjing (Tao, 1987) city used Rutter’s diagnostic criteria (Lotter, 1966) and assessment of cases was different from
the other Chinese studies. After excluding these three studies, the reported prevalence was between 1.1/10,000 and 21.8/
10,000. Since there were great differences in study methodology between the studies, they were sorted into two categories
according to the similar screening instruments used and the same diagnostic criteria applied in determination of cases. Using
different screening instruments across studies could have had an impact on the prevalence of ASD (Fig. 2).
Overall, the prevalence of ASD was higher than reported in earlier Japanese studies when the HC-18 was used as a screening
tool. Similarly, the prevalence in China was higher when the CABS was used as a screening tool. Six studies (Chen et al., 2007;
Table 2
Case ascertainment methods.

No. Screening strategy Screening source Diagnostic strategy Diagnostic criteria Age No. of cases Population

1 – – – Kanner 2–12 – –
2 – – – Kanner 15 – –
3 – – – Kanner 5–14 – –
4 – – – Kanner – – –
5 Questionnaire requesting Mainstream and special schools, Parents and child interviews Kanner 0–18 – 609,848
behavioural descriptions medical and welfare institutions
6 Letter to elicit referrals All schools and medical institutions – DSM-III 6–12 56 35,000
7 Referral to local records All schools and medical institutions Questionnaire + direct clinical DSM-III 4–12 54 32,834
examination
8 Referral to local records Health centre (Nanjing Child Mental Review of available data Rutter 5 68 457,200

X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167

Health Research Center)
9 Health checklist-18 Health centre (Tsuchiura Child Review of available data DSM-III 7 132 597,003
Guidance Center)
10 Health checklist-18 Health centre (Midori Public Health Tumori Developmental Scale DSM-III 1.5 16 12,263
Center) (Gessel) + direct observation
+ examination
11a Referral to local records Educational and medical institute Review of available data DSM-III-R 6–14 49 35,366
12a 19-items Bryson’s screening scale Professionals trained in using the Psychiatric interview + WISC-R Children autism rating 4–7 6 5,120
screening instrument + Merrill-Palmer scale (CARS)
13 Health checklist-18 Health centre (Yokohama Direct observation + psychological ICD-10 5 18 8,537
Rehabilitation Center) assessments + review of data
14 ABC (Autism Behavior Checklist) Fujian Medical Institute + Mental Questionnaires + direct observation CCMD-2-R (Chinese 14 3 10,802
Health Research Center children mental
diagnosis), DSM-III-R
15 Referral local records Health centre (Children Development Review of available data DSM-III-R/IV 8–12 26 26,160
Center)
16 CABS (Clancy Autism Behavior Scale) Changzhou Medical Institute Questionnaires + direct observation CARS + general development 2–6 7 3,978
by pediatricians scale and childhood
psycho-education rating scale
17 CABS Changzhou Medical institute Questionnaires + direct observation CCMD-2-R CARS, PEP Gassel 2–6 9 7,488
+ Mental Health Center by pediatricians
18 CABS + parents questionnaire Children Health Center of Questionnaires CABS 3–5 89 3,559
Anhui Province
19 Referral local records Medical institute Review available data – 14 1004 1,113,900
20 CABS Special education + rehabilitation Questionnaires + direct observation CCMD-2-R CARS, PEP 2–6 5 3,606
centre (Tianjin) by pediatricians
21 Health checklist-18 + other referrals Health centre (Yokohama Direct observation + psychological ICD-10 5 68 35,716
to local psychiatric services Rehabilitation Center) assessments + review of data
22 CSI-4 (child symptom inventory-4) Education (primary school) Questionnaires DSM-IV PDD 5–10 38 2,000
23 ABC Medical Institute of Women Questionnaires + direct observation DSM-IV 3–12 6 10,412
and Children by pediatricians
24 Age > 3 CABS Age < 3 CHAT + DDST Medical Institute of Children Questionnaires + direct observation CARS + DSM-IV 1–6 25 25,521
by pediatricians
25 Health checklist-18 Health centre + education (Toyota Direct observation + psychological DSM-IV 5 16 12,263
Municipal Child Development Center) assessments + review of data
26 Referral local records National Health Insurance Review available data ICD-9 12 1,339 328,802
Research Institute
(–) No details given from previous reviews and not possible to gain the original papers.
a
Studies were cited in previous reviews.

159

Table 3
Main diagnostic criteria used in Asia.
Diagnostic criteria ICD-10
Impairment in social 1. Failure to use non-verbal communication
interaction to regulate social interaction
2. Failure to develop peer relationships
that involve a mutual sharing of interests
and emotions
3. Lack of social-emotional reciprocity
4. Lack of spontaneous seeking to share
enjoyment, interests or achievements
with other people
Impairment in social 1. A delay, or a total lack of development
communication of spoken language that is not accompanied
by an attempt to compensate through
the use of non-verbal communication
2. Relative failure to initiate or sustain
conversational interchange in which
there is reciprocal responsiveness to
the other person
DSM-IV
1. Marked impairments in the use
of multiple non-verbal behaviours
such as eye-to-eye gaze, facial expression,
body posture, and gestures to regulate
social interaction
2. Failure to develop peer relationships
appropriate to developmental level
3. A lack of spontaneous seeking to share
enjoyment, interests, or achievements
with other people, (e.g. by a lack of showing,
bringing, or pointing out objects of interest
to other people)
4. Lack of social or emotional reciprocity
(examples: not actively participating in
simple social play or games, preferring
solitary activities, or involving others in
activities only as tools or ‘‘mechanical’’
aids)
1. Delay in, or total lack of, the
development of spoken language
(not accompanied by an attempt to
compensate through alternative
modes of communication such as
gesture or mime)
2. In individuals with adequate speech,
marked impairment in the ability to
initiate or sustain a conversation with
others
160
CCMD-3
X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167
1. Lack of interest in social games, lonely,
cannot generate response to social
happiness
2. Failure to develop peer relationships
appropriate to developmental level and
lack of technique to communicate with
others (e.g. only communicating by
dragging, pushing or hugging other
people)
3. Lack of social or emotional reciprocity
(e.g. preferring solitary activities and lack
of communication with surroundings)
4. Marked impairments in the use of
multiple non-verbal behaviours such as
eye-to-eye gaze, facial expression, body
posture, and gestures to regulate social
interaction
5. Failure to play social games or imitative
games
6. When they are discomfort or unhappy,
they don’t seek for sympathy or comfort
and they don’t show sympathy or comfort
to others either
1. A delay, or a total lack of development
of spoken language, not use gesture or
imitation to communicate
2. Impairment in language understanding,
usually cannot understand instruction or
order, failure to show need and seldom
ask questions and lack of reaction to others
 3. Stereotyped and repetitive use of
language or idiosyncratic use of words
or phrases
4. Lack of varied spontaneous make-believe
or social imitative play
3. Stereotyped and repetitive use of
language or idiosyncratic language
4. Lack of varied, spontaneous make-believe
play or social imitative play appropriate
to developmental level

Repetitive and 1. An encompassing preoccupation with
stereotyped patterns one or more stereotyped and restricted
patterns of interest
2. Apparently compulsive adherence to
specific, non-functional routines or rituals
1. Encompassing preoccupation with
one or more stereotyped and restricted
patterns of interest that is abnormal
either in intensity of focus
2. Apparently inflexible adherence to
specific, non-functional routines or rituals
1. Refuse to change stereotyped gesture or
activity, otherwise they will show irritated
and restless
2. Persistent preoccupation with parts of
objects such as a piece of paper, smooth
cloth, wheels and usually get great
satisfactory form it

X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167

3. Stereotyped and repetitive motor
mannerisms
4. Preoccupations with part-objects/
non-functional elements of play materials
3. Stereotyped and repetitive motor 3. Apparently inflexible adherence to
mannerisms (e.g. hand or finger flapping specific, non-functional routines or rituals
or twisting, or complex whole-body
movements)
4. Persistent preoccupation with parts
of objects

161
162 X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167

Fig. 1. The ‘‘fall-safe’’ system of autism in Japan (Honda et al., 2005).

Davidovitch, Holtzman, & Tirosh, 2001; Kamer et al., 2004; Matsuishi et al., 1987; Ohtaki et al., 1992; Tao, 1987) in four different
countries used available records from databases to identify cases which is a weakness of these studies since they did not attempt
to verify that any of the cases were true cases. The generalizability of these data is unknown. The diagnostic and screening
instruments applied in determining these cases may have differed in each case, even within the same database.

2.4. Prevalence estimates after 1980

Eight out of 21 studies after 1980 carried out the diagnostic assessment by questionnaire plus direct observation by
psychiatrists. Six studies used available databases and three studies employed a combination of direct observation and
previous data from clinical records. Another three studies used parents’ interviews or questionnaires. One study
(Wignyosumarto, Mukhlas, & Shirataki, 1992) used the Wechsler Intelligence Scale for Children and the Merrill-Palmer Scale
of Mental Tests after direct observation to determine IQ ability. Differences in observation and examination among
practitioners make it difficult to compare the results.
There are nearly ten sets of diagnostic criteria for ASD in Asia. Since 1980, 7 out of 13 Japanese studies used ICD-10 or
DSM-III/IV. In China, half of the studies used the CARS and the Chinese Children Mental Diagnosis (CCMD (1993)) but no
sensitivity and specificity data have been reported. Since these studies used different diagnostic criteria, it is reasonable to
report prevalence separately. After adopting DSM-III/IV or ICD-10 as the diagnostic criteria, the prevalence of ASD increased
dramatically in Japan but decreased in China. Additionally, the prevalence in Japan using ICD-10 or DSM-III/IV was higher
than in the studies in China using the same diagnostic criteria (Fig. 3).

2.5. Time trends

Japan began research into the prevalence of ASD much earlier than China and other countries in Asia. The prevalence of
ASD in both Japan and China appears to have increased over time (Fig. 4). The Yokohama (Honda et al., 2005) study that was
conducted in the same catchment area from 1994 to 1997 (Table 7) showed an increase in the prevalence of ASD during these
years. Studies from both Japan and China tried to explain this trend, but due to the lack of homogenous case definition and
case ascertainment, the prevalence estimates may easily have been inflated and skewed.

2.6. Geographical areas

Overall, the prevalence of ASD in Japan was higher than the other Asian countries. The median prevalence was 15.5/
10,000 in Japan and 10.4/10,000 in China. Besides two Japanese studies in the same city (Yokohama) (Honda et al., 2005,
1996), another six studies (Chen et al., 2007; Davidovitch et al., 2001; Ghanizadeh, 2008; Kawamura et al., 2008; Wang et al.,
2003; Zhang et al., 2008) took geography into consideration. Two studies (Zhang et al., 2008; Wang et al., 2003) reported
higher prevalence in urban compared to rural areas. Another Japanese study in Toyota (Kawamura et al., 2008; Wang et al.,
2003) compared their results with the Yokohama (Honda et al., 2005) study and suggested that the lower prevalence
estimate in Toyota might derive from the differences in diagnostic criteria and the larger population size in Toyota.
Table 4
Screening instruments in Asia.
Screening instruments HC-18 (Kawamura et al., 2008)
Type of usage Questionnaire
Impairments in 1. Pointing to request or show
Social interaction
2. Poor eye vision,
3. Does not play with others
Impairments in 1. Cannot understand simple
Communication instructions
2. Cannot speak meaningful
words
3. Pretending
4. Limited reaction and answer
5. Does not imitate other people
Repetitive and stereotyped 1. Persistent preoccupation
patterns of interest with some objects
and behaviours
2. Tower of bricks
HC-18: health checklist for 18-month old; CHAT: checklist for autism toddlers; ABC: autism behaviour checklist; CABS: children autism behaviour scale; CSI: children symptom inventory.
CHAT ABC (Miranda-Linne,
(Wong et al., 2004) Fredrika M. & Melin, L., 2002)
Questionnaire Description of symptoms
1. Does not play with 1. No interest in social play
others or friendship
2. Pointing to request or 2. Does not answer or react
show interest
3. No interest in social 3. Lack of social expression
reciprocity
4. Avoids eye contact 4. Avoids eye contact
5. Difficult to hold
6. Gestures
7. Poor eye contact
1. Pretending 1. Cannot understand simple
instructions
2. Cannot understand 2. Repetitive word usage
simple instructions
3. Does not imitate other people
4. Uses five or less words to
communicate
1. Rough and tumble 1. Inappropriate toys
play
2. Tower of bricks 2. Adaptation to change
3. Toe walking or spinning
4. Complicated ‘‘rituals’’,
destructive in nature
CABS (Xuerong Li &
Jinmei Chen, 2004)
Description of symptoms
1. Does not want to play with
other children
2. No response to name, seems
to be deaf
3. Smiles with no reason
4. Does not like to be held
5. Avoids directly looking at
faces and eye contact
6. Expresses needs by gesture
1. Strongly resists learning such
as refusing to imitate, speak
or act
2. Indifferent to surroundings
1. Likes rolling objects
2. Repeats odd actions or play
3. Restless, moves continually
and behaves hyperactively
4. Persistent preoccupation
with some objects
5. Likes rolling objects
5. Repeats bizarre actions or play
CSI-4 (Gadow, Schwartz, Devincent,
Strong, & Cuva, 2008)
Observational items
1. Does not want to play with
X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167
other children
2. Lack of peer relationship
3. Particular way of relating to
others
4. Not interested in pleasure
activities
5. Not interested in making friends
1. Difficulty following instructions
2. Difficulty organizing tasks and
pretending
3. Poor attention to detail
4. Talks in strange way
5. Difficulty in making conversation
1. Difficulty remaining seated
2. Difficulty playing quietly
3. Easily annoyed
4. Difficulty waiting for turn
5. Makes repetitive movements
5. Fascination with parts of objects
163
164 X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167

Table 5
Prevalence of ASD in Japan (1971–2008).

Study number Year Age Prevalence (per 10,000) Population size Sex ratio (male:female)

1 1971 2–12 2.6 – –

2 1971 0–15 1.7 – –
3 1971 5–14 1.1 – –
5 1971 0–18 2.3 609,848 –
6 1983 6–12 16 35,000 –
9 1988 0–7 13.8 507,003 4.1:1
10 1989 0–5 13 12,263 2.1:1
11 1992 6–14 11.7 35,366 –
13 1996 0–5 21.1 8,537 2.6:1
21 2005 0–5 19 35,716 2.5:1
25 2008 0–5 13 12,263 2.8:1

(–) No details given from previous reviews or not possible to gain the original papers.

Table 6
Prevalence of ASD in China (1987–2008).

Study number Year Age Prevalence (per 10,000) Population size Sex ratio (male:female)

8 1987 0–5 0.32 457,200 6.5:1

14 2000 0–14 2.8 10,802 4.1:1
16 2002 2–6 17.9 3,978 2.5:1
17 2003 2–6 12.3 7,488 2:1
20 2004 2–6 13.8 3,606 All male
23 2007 3–12 5.6 10,412 5:1
24 2008 1–6 9.8 25,521 3.2:1

Fig. 2. Prevalence and screening sources in Japan and China (1980–2008). M: medical institutes; H: health centres; E: educational institutes.

Fig. 3. Prevalence and diagnostic criteria (1970–2008).

2.7. Birth variables

One Japanese study in Ibaraki (Tanoue et al., 1988) found the prevalence of autism clustered by both birth year and month
of birth. They found a higher prevalence of autism in children born between April and June during 1972–1978. In most (86%)
 X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167 165

Fig. 4. Time trends of ASD in Japan and China.

Table 7
Prevalence of ASD in Yokohama (Honda et al., 2005).

Year of collection Year of birth Prevalence (per 10,000)

1994 1988 21.1

1995 1989 38.2
1996 1990 50.3
1997 1991 41.2

of the cases in seven Chinese studies (Guo, 2009; Lou et al., 2000; Ren et al., 2003; Wang et al., 2002, 2003; Yang et al., 2007;
Zhang et al., 2008) only one child in the family was affected.

2.8. Ethnic background and migration

Two studies (Kamer et al., 2004; Tanoue et al., 1988) compared native residents with immigrants and found the
prevalence of ASD in the former to be higher. However, there was no other evidence available to justify the relationship
between ethnicity and prevalence in other regions of the world.

2.9. Educational level

All the Chinese studies suggested higher educational level of parents may be more related to the high prevalence of
childhood autism, while the Chinese study in Fujian (Lou et al., 2000) province discussed the educational level of autistic
children. Only one study in Tongling (Ren et al., 2003) reported that the higher prevalence of ASD was related to the lower
educational level of parents, especially mother’s educational level. This study found the highest prevalence among children
whose mothers only attended primary school (3.6%) and the lowest among children whose mothers graduated from college
(1.1%, x2 = 20.62, p  0.0001). However, this study only used screening without further diagnosis, so this finding might not
reliable.

2.10. Socioeconomic status

Five studies (Guo, 2009; Ren et al., 2003; Wang et al., 2003; Yang et al., 2007; Zhang et al., 2008) provided information on
the socioeconomic background of families and two studies (Guo, 2009; Zhang et al., 2008) provided the annual income of
parents. There was no evidence of a relationship between the prevalence of ASD and socioeconomic status. Many studies
(Chen et al., 2007; Ghanizadeh, 2008; Honda et al., 2005) suggested that the improvement of living conditions and awareness
could be partly responsible for the increase of prevalence.

3. Discussion

3.1. Summary of findings

In summary, epidemiological research on the prevalence of ASD in Asia has been conducted in six countries from 1971 to
2008. Methodological differences in case definition, screening instruments and diagnostic criteria were evident between
countries which makes it very difficult to compare the studies. However, despite these differences, some common
characteristics appeared within these population surveys. Prevalence of ASD seemed to be higher in children of 2–6 years
old. Boys had a higher prevalence than girls which is also found in Western studies (Blaxill, 2004). Estimates of prevalence
were also higher in urban than rural areas. Generally, the estimated prevalence in Japan was higher in more recent surveys
especially after adopting DSM-IV and ICD-10 as well as using the HC-18 as the screening tool. In China, studies which used
166 X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167

the CCMD and CABS suggested an increase of prevalence over time. Some studies also revealed an association between an
increase in prevalence with younger children, lower educational level of parents, native residents and urban areas.
Previous studies (Fombonne, 2003) have suggested the larger the population size, the lower the prevalence of ASD.
However, this trend was not evident in Asia. The effects of differences in screening instruments and diagnostic criteria
employed were the key factors in the differences in prevalence estimates. Many of the items in the screening instruments
and diagnostic criteria are similar, but the prevalence of ASD in different countries varied greatly. Therefore, potential
explanations need to be further examined.

3.2. Critique of methods

The studies which were in English were selected from Pubmed and Web of Knowledge only. Since only 17 studies met the
inclusion criteria, there might be selection bias. Since studies published in other databases were not included in this review,
it is possible that inclusion of studies from other databases might provide contrasting results. Additionally, only the full text
of 17 studies could be obtained, and information about the other 9 studies was obtained from previous reviews. Since the
details of those studies were unknown, information that had not been provided in the reviews could change the results.
Only seven studies from China could be found in the Chinese database and they were published in Chinese with English
abstracts. Therefore, publication bias may be present due to the validity of using this database. As the information was
translated into English, there might be mistranslation which could have affected the analysis.
There are some limitations to the studies selected in this review: first, studies that used pre-existing databases may not be
generalizable since those data were collected at different times rather than drawing from a complete census of the whole
population; second, the different diagnostic procedures employed within each study might have produced misclassification
bias; third, response to the screen was generally not reported in the studies, bringing into question the generalizability of the
results; fourth, the population size varied across studies which makes the comparison between studies difficult; fifth, these
studies only covered six countries in Asia which may lack generalizability across Asia as a whole.

4. Conclusions and recommendations

This review cannot resolve the issue of whether or not the increase in prevalence of ASD is real, or simply due to the
changes in diagnostic criteria and better case ascertainment. The major difficulties surrounding estimating the prevalence of
ASD in Asia are in the differences in screening instruments and diagnostic criteria within different countries, so it is
preferable to have common methodology in future research. Since many studies could not be obtained due to the limitation
of language, there is a need to address this issue in order to obtain more reliable information, worldwide. Most of the Chinese
studies were very short and very different in design from Western studies, so more high quality surveys are required. Some
countries in Asia such as Korea (Kim, Kim, Park, Cho, & Yoo, 2007) and Singapore (Ooi et al., 2008) conducted aetiological
research on autism while prevalence data are lacking. Thus, more research in the prevalence of ASD is required in those
countries.

Acknowledgement

We are grateful to Professor Carol Brayne for her comments on an earlier draft of this paper.

References

Baird, G., Simonoff, E., Pickles, A., Chandler, S., Loucas, T., Meldrum, D., et al. (2006). Prevalence of disorders of the autism spectrum in a population cohort of
children in South Thames: The Special Needs and Autism Project (SNAP). Lancet, 368210–368215.
Blaxill, M. F. (2004). What’s going on? The question of time trends in autism. Public Health Reports, 119536–119551.
Charman, T., Loucas, T., Pickles, A., Simonoff, E., Chandler, S., Meldrum, D., et al. (2008). Autistic symptomatology and language ability in autism spectrum disorder
and specific language impairment. Journal of Child Psychology and Psychiatry, 49(11), 1184–1192.
Chen, C. Y, Liu, C. Y., Su, W. C., Huang, S. L., & Lin, K. M. (2007). Factors associated with the diagnosis of neurodevelopmental disorders: A population-based
longitudinal study. Pediatrics 119e435–119e443.
Davidovitch, M., Holtzman, G., & Tirosh, E. (2001). Autism in the Haifa area—An epidemiological perspective. Israel Medical Association Journal, 3188–3189.
Fombonne, E. (2003). Epidemiological surveys of autism and other pervasive developmental disorders: An update. Journal of Autism and Developmental Disorders,
33365–33382.
Gadow, K. D., Schwartz, J., Devincent, C., Strong, G., & Cuva, S. (2008). Clinical utility of Autism Spectrum Disorder Scoring Algorithms for the Child Symptom
Inventory-4. Journal of Autism Developmental Disorders, 38, 419–427.
Ghanizadeh, A. (2008). A preliminary study on screening prevalence of pervasive developmental disorder in schoolchildren in Iran. Journal of Autism and
Developmental Disorders, 38759–38763.
Gillberg, C., & Wing, L. (1999). Autism: Not an extremely rare disorder. Acta Psychiatrica Scandinavica, 99399–99406.
Guo, Rong. (2009, February 25). Epidemiological investigation analysis of 5000 children between 0–6 years old with children autism in Tianjin City. Chinese Journal
of Clinical Rehabilitation, 18(6), 1122–1123.
Honda, H., Shimizu, Y., Misumi, K., Niimi, M., & Ohashi, Y. (1996). Cumulative incidence and prevalence of childhood autism in children in Japan. British Journal of
Psychiatry, 169228–169235.
Honda, H., Shimizu, Y., Imai, M., & Nitto, Y. (2005). Cumulative incidence of childhood autism: A total population study of better accuracy and precision.
Developmental Medicine and Child Neurology, 4710–4718.
Hoshino, Y., Kumashiro, H., Yashima, Y., Tachibana, R., & Watanabe, M. (1982). The epidemiological study of autism in Fukushima-ken. Folia Psychiatrica et
Neurologica Japonica, 36115–36124.
 X. Sun, C. Allison / Research in Autism Spectrum Disorders 4 (2010) 156–167 167

Hughes, J. R. (2008). A review of recent reports on autism: 1000 studies published in 2007. Epilepsy and Behavior, 13425–13437.
Ishii, T., & Takahashi, O. (1983). The epidemiology of autistic children in Toyota, Japan. Japanese Child & Adolescent Psychiatry, 24, 311–321.
Kamer, A., Zohar, A. H., Youngmann, R., Diamond, G. W., Inbar, D., & Senecky, Y. (2004). A prevalence estimate of pervasive developmental disorder among
immigrants to Israel and Israeli natives—a file review study. Social Psychiatry and Psychiatric Epidemiology, 39141–39145.
Kawamura, Y., Takahashi, O., & Ishii, T. (2008). Reevaluating the incidence of pervasive developmental disorders: Impact of elevated rates of detection through
implementation of an integrated system of screening in Toyota, Japan. Psychiatry and Clinical Neurosciences, 62152–62159.
Kim, S. A., Kim, J. H., Park, M., Cho, I. H., & Yoo, H. J. (2007). Family-based association study between GRIK2 polymorphisms and autism spectrum disorders in the
Korean trios. Neuroscience Research, 58332–58335.
Li, Xuerong, & Chen, Jinmei. (2004). Diagnosis of Autism. Changsha: Central South University Press. 57–100.
Lotter, V. (1966). Epidemiology in autism conditions in young children. Social Psychiatry, 1, 124–137.
Lou, Weiwu, Lin, Li, & Chen, Rong. (2000). Epidemiological investigation on autistic disorder in Fujian Province. Shanghai Archived of Psychiatry, 12(1), 3–5.
Matsuishi, T., Shiotsuki, Y., Yoshimura, K., Shoji, H., Imuta, F., & Yamashita, F. (1987). High prevalence of infantile autism in Kurume City, Japan. Journal of Child
Neurology, 2268–2271.
Miranda-Linne, Fredrika M. , & Melin, Lennart. (2002). A factor analytic study of the Autism Behavior Checklist. Journal of Autism and Developmental Disorders,
32(3), 181–188.
Ohtaki, E., Kawano, Y., Urabe, F., Komori, H., Horikawa, M., Yamashita, Y., et al. (1992). The prevalence of Rett syndrome and infantile autism in Chikugo District,
the southwestern area of Fukuoka prefecture, Japan. Journal of Autism and Developmental Disorders, 22452–22454.
Ooi, Y. P., Lam, C. M., Sung, M., Tan, W. T., Goh, T. J., Fung, D. S., et al. (2008). Effects of cognitive-behavioural therapy on anxiety for children with high-functioning
autistic spectrum disorders. Singapore Medical Journal, 49215–49220.
Ren, Luzhong, Duan, Zongzhi, & Xu, Jin. (2003). An analysis on positive of rate autism among preschool children in city. Chinese Journal of Child Care, 2, 105–107.
Sugiyama, T., & Abe, T. (1989). The prevalence of autism in Nagoya, Japan: A total population study. Journal of Autism and Developmental Disorders, 1987–1996.
Tanoue, Y., Oda, S., Asano, F., & Kawashima, K. (1988). Epidemiology of infantile autism in southern Ibaraki, Japan: Differences in prevalence in birth cohorts.
Journal of Autism and Developmental Disorders, 18155–18166.
Tao, K.-T. (1987). Brief report: Infantile autism in China. China Journal of Autism and Developmental Disorders 17(2).
Wang, Weihua, Zai, Li, & Li, Z. (2002). An epidemiological investigation on autistic disorder in Changzhou. Clinical Psychological Medicine, 12(3), 148–149.
Wang, Weihua, Zai, Li, & Li, Z. (2003). An epidemiological investigation on autistic disorder in Jangsu Province. Behaviour Medical Science in China, 12(2), 173–174.
Wignyosumarto, S., Mukhlas, M., & Shirataki, S. (1992). Epidemiological and clinical study of autistic children in Yogyakarta, Indonesia. Kobe Journal of Medical
Sciences, 381–419.
Williams, J. (2003). Screening for autism spectrum disorders. University of Cambridge.
Wong, V., Hui, L. H., Lee, W. C., Leung, L. S., Ho, P. K., Lau, W. L., et al. (2004). A modified screening tool for autism (Checklist for Autism in Toddlers [CHAT-23]) for
Chinese children. Pediatrics, 114.2, e166–e176.
Yang, Shuguang, Hu, Yuezhang, & Han, Yun. (2007). Prevalence investigation of Autism in Children. Journal of Applied Clinical Pediatrics, 22(24), 1872–1873.
Zhang, Feng, Sui, Qian, & Wang, Jie. (2008). The latest investigation of autism epidemic of children aged from 1 to 6 years old. Chinese Women and Children
Healthcare, 23, 3878–3879.