Final Thesis in Process

INTRODUCTION
The word “autism” emanates from a Greek word “autos” which means “self”,
It narrates a conditions in which a person is removed from social interaction -
hence, an isolated self (Kuhn and Cahn, 2004). 'Autism spectrum disorder'
(ASD) was introduced by Wing in 1996 (Henshell, 2008). Autism is a
neurodevelopmental syndrome that is defined by deficits in social reciprocity
and communication, and by unusual restricted, repetitive behaviors (American
Psychiatric Association, 2000).
Autism Spectrum Disorder is now defined by two categories: (a) impaired

social communication and/or (b) interaction and restricted and/or repetitive
behaviors (APA, 2013). As of 2014, the Centers for Disease Control and
Prevention estimate that autism affects 1 in 68 children (CDC, 2014). People
with ASD commonly also have language difficulties, and around 25% to 30%
of children are unable to use verbal language to communicate or are minimally
verbal (use fewer than 30 words).
Restricted and repetitive behaviors (RRBs) are hallmark symptoms of autism

spectrum disorders (ASDs); however, it has proven difficult to understand the
mechanisms that causes these behaviors. (Susan et al., 2013). Some
researchers have hypothesized that RRBs are a consequence of disordered.
Some researchers have hypothesized that RRBs are a consequence of
disordered selective attention.
Few would dispute that the causes of ASD include both genetic and
environmental factors. Indeed, more than 100 genes are known to confer risk,
and 1,000 or more may ultimately be identified (De Rubeis, et al.. 2014).
Some studies have shown that people with autism tend to have more copied
genetic mutations. A wide range of potential environmental challenges have
also been associated with autism, although studies in this area lag behind
genomics research.
Genetic factors play a role in ASD susceptibility, many of the genetic defects
associated with ASD encode proteins that are relevant at the neuronal synapse
or that are involved in activity-dependent changes in neurons (Kim et
1
al., 2018). Sufferers of Fragile X share very similar traits to those on the
autistic spectrum in that it is an intellectual disability. A small explorative
study of neocortical architecture from young children revealed focal disruption
of cortical laminar architecture in the majority of subjects, suggesting
problems with cortical layer formation and neuronal differentiation (De
Rubeis et al., 2014).
Brain overgrowth both in terms of cortical size and additionally in terms of

increased extra-axial fluid have been described in children with ASD (Shen et
al., 2017). Prenatal exposure to thalidomide and valproic acid have been
reported to increase risk, while studies suggest that prenatal supplements of
folic acid in patients exposed to antiepileptic drugs may reduce risk (Surén et
al., 2013). Advanced maternal and paternal age have both been shown to have
an increased risk of having a child with ASD.
Maternal history of autoimmune disease, such as diabetes, thyroid disease, or
psoriasis has been postulated, but study results remain mixed. Maternal
infection or immune activation during pregnancy is another area of interest
and may be a potential risk factor according to recent investigations (Malkova
et al., 2012). Obstetric factors including uterine bleeding, caesarian delivery,
low birthweight, preterm delivery, and low Apgar scores were reported to be
the few factors more consistently associated with autism.
In the largest single study to date, there was not an increased risk after
measles/mumps/rubella (MMR) vaccination in a nationwide cohort study of
Danish children (Hviid et al., 2019). Small increases in autism risk have been
reported if, for example, a family lives closer to a freeway or to an agricultural
area during pregnancy (Mandy, 2016). People of all genders, races, ethnicities,
and economic backgrounds can be diagnosed with ASD. Although ASD can
be a lifelong disorder, treatments and services can improve a person’s
symptoms and daily functioning.
Individuals with ASD have been found to have high rates of abnormalities of
sensory functioning. (Marco et al., 2011). Social communication and
interaction skills can be challenging for people with ASD. Self-injurious
behaviors (SIBs) are consistently present as a separate subgroup of repetitive
2
behaviors in factor analysis studies (Bishop et al., 2013). In addition to
difficulties in attention shifting, some children with ASD have difficulties in
selective attention, which dictates what information in the environment should
be focused on and what information should be ignored. Anxiety disorders are
highly comorbid in individuals with ASD, with prevalence rates ranging from
11% to 84%.
Several standardized screening tools exist to diagnose ASD at an early age,

these include the Screening Tool for Autism in Toddlers and Young Children
(STAT), (Zwaigenbaum et al., 2018) the longer and widely researched Autism
Diagnostic Observation Schedule (ADOS), (Blank et al., 2020). The
Diagnostic Instrument for Social Communication Disorders (DISCO) and the
Autism Diagnostic Interview-Revised (ADI-R), other screening tools such as
the Social Responsiveness Scale (SRS), the Social Communication
Questionnaire (SCQ), and the Childhood Autism Rating Scale (CARS) can be
used to assess a child’s symptoms of ASD. While many tools to screen and
diagnose ASD exist, two of the leading autism diagnostic tools in use today
are DSM-5 and M-CHAT (Modified Checklist for Autism in Toddlers).
Whether and to what extent ASD can or should be treated is a controversial

topic, especially considering the noticeable heterogeneity within ASD
children. Many approaches are available to improve the abilities and skills,
and quality of life of individuals with ASD (Oswald et al., 2018). These
approaches involve families, clinical practitioners, and educators (Lord et al.,
2020). However, to date, information on positive outcomes of a specific
intervention, and the mechanism that leads to these improvements is scant
(Weitlauf et al., 2014).
The World Health Organization (WHO) estimates the international prevalence

of ASD at 0.76%; however, this only accounts for approximately 16% of the
global child population (Baxter et al., 2015). Current prevalence is estimated

to be at least 1.5% in developed countries, with recent increases primarily
among those without comorbid intellectual disability. The prevalence of
typical autism across the world is generally reported to be 10 per 10,000. ASD
occurs in all racial, ethnic, and socioeconomic groups, but its diagnosis is far
3
from uniform across these groups. Caucasian children are consistently
identified with ASD more often than black or Hispanic children (Baio et al.,
2014).
ASD is more common in males (Tartaglia et al., 2017) but in a recent meta-
analysis (Loomes et al., 2017), true male-to-female ratio is closer to 3:1. The
median male-to-female ratio was 4.2. Not only are females less likely to
present with overt symptoms, they are more likely to mask their social deficits
through a process called “camouflaging”, further hindering a timely diagnosis
(Volkmar et al., 2014). Likewise, gender biases and stereotypes of ASD as a
male disorder could also hamper diagnoses in girls (Bargiela et al., 2016).
4
5
LITERATURE REVIEW
Autism is a complex disorder with varying degrees of impairment in areas like
communication skills, social interactions, and restricted, repetitive, or
stereotyped patterns of behavior. Approximately 1/100 children were
diagnosed with ASD worldwide. Prevalence estimates increased over time and
varied greatly within and across socio-demographic groups. In recent years,
the World Health Assembly adopted WHO's Comprehensive Mental Health
Action Plan 2013–2020. The median prevalence of ASD was 62/10,000
children, in 2012, with a consistently higher prevalence in boys (Elsabbagh et
al., 2012). Studies that were included had as a primary aim to estimate the
prevalence of ASD since 2012. According to the up-to-date global estimate of
ASD prevalence, studies revealed a median prevalence of 65/10,000.
(Christensen et al., 2019).
Current prevalence was estimated to be at least 1.5% in developed countries

(Baxter et al., 2015). Onset of ASD symptoms typically occurs by age 3,
symptoms can emerge between 6 and 18 months. Common ASD-associated
impairments include intellectual disability and attention disabilities,
(Christensen et al., 2012.) as well as sensory sensitivities, gastrointestinal
problems, immune deficits, anxiety and depression, sleep disturbances, and a
range of comorbid medical conditions (Croen et al., 2015). Genetic factors,
environmental factors (Schieve et al., 2015), or different combinations of the
above have all been suggested to play a major role in the pathogenesis of
ASD. Up to 15% of cases can be linked to a known genetic cause via
monogenic syndromes (such as Fragile X syndrome, Tuberous Sclerosis, and
Timothy Syndrome) (Devlin and Scherer, 2012).
A CDC–sponsored surveillance project to determine and monitor the

prevalence of ASD in the general population, estimate that approximately one
in 68 eight-year old children in 2010 had an ASD, an increase of 123% from
the 2002 prevalence. Maenner et al., (2014) found that the prevalence of ASD
was 11.3 per 1000 when applied Diagnostic and Statistical
Manual, 4th Edition–Text Revision (DSM-IV TR) criteria, versus 10 per 1000
when applied DSM-5 (Maenner et al., 2014). According to CDC
5
6
approximately 20% of children meeting the ADDM case definition of ASD

did not have prior clinical diagnoses or educational classifications of ASD.
Thus, population-based screening and assessment may identify children with
ASD who would otherwise go undetected.
Changes in autism diagnostic criteria found in DSM-5 may affect autism

spectrum disorder (ASD) prevalence, research findings, diagnostic processes,
and eligibility for clinical and other services. Using the published, total-
population Korean prevalence data, DSM-5 ASD and social communication
disorder (SCD) prevalence was computed and compared with DSM-
IV pervasive developmental disorder (PDD) prevalence estimates in 2014. The
target population was all children from 7 to 12 years of age in a South Korean
community (N = 55,266), those in regular and special education schools, and a
disability registry. Autism Spectrum Screening Questionnaire for systematic,
multi-informant screening. DSM-5 ASD estimated prevalence was 2.20%.
Combined DSM-5 ASD and SCD prevalence was virtually the same as DSM-
IV PDD prevalence (2.64%). Most children with autistic disorder
(99%), Asperger disorder (92%), and PDD-NOS (63%) met DSM-5 ASD
criteria, whereas 1%, 8%, and 32%, respectively, met SCD criteria (Kim et al.,
2014).
A study was conducted at Tertiary Care Hospital Rawalpindi, from Jun to Nov
2018. The sample population comprised of 1889 adult patients reporting for
psychiatric evaluation. Autism Spectrum Disorder and Attention Deficit
Hyperactivity Disorder were screened by using screening tools which were
Adult Autism Spectrum Quotient (AQ) and ADHD Self-Report Scale-V1
respectively. Relationship of age, gender, socioeconomic status, illicit
substance use, marital status, education and response to treatment was
assessed with the presence of ASD and ADHD. Out of 1889 adult patients
screened through AQ and ASRS, 78.9% were screened negative on both the
screening tools while 12.5% were positive on AQ and 13.5% were positive on
ASRS. About 8.6% of the screening positive patients had diagnosis of ASD
and 11% had diagnosis of ADHD. Ten patients had both ASD and ADHD
(Khan et al., 2019).
6
7
A study with a cluster sample of 6,365 children found 6.5 % rates of mild
mental retardation and 1.9 % of serious cognitive disability (Bashir et al.,
2002). An estimate of 19.0/1,000 children suffering from mental
retardation/learning disability was also observed in Karachi (Durkin, 2002).
Nearly 16 per 1,000 children between 3 and 9 years of age suffer from severe
mental retardation according to another research (Mubbashar and Saeed,
2001). Morton et al., (2002) noted that Pakistani children had a slightly
increased prevalence of autism (2.57/1,000) (Morton et al., 2002). Autism was
also believed to be a precursor of schizophrenia by majority of HCP (Imran et
al., 2011). A methodologically sound two-stage survey by Hussein et al. in
2011 found prevalence of emotional and behavioral problems to be around 17
% in 5–11 years old children in Karachi city schools, which was among the
highest in the developing world.
The first autism surveys were simple prevalence was low, ranging from 0.4 to
2/1,000 in the 1960's and 1970's. New Jersey exhibited a rate of 2.93% (Baio
et al., 2018) whereas South Carolina was about to reveal a blow-out estimate
of 3.62% (Carpenter et al., 2017). Today, the methodology of surveys has
become more complex. First, screening tools such as the Social
Responsiveness Scale, the Social Communication Questionnaire and second,
and most importantly, there is relatively low participation (36%–63%) to the
initial screening and in other survey phases (e.g. participation to a diagnostic
confirmation session). Because the previous two CDC surveys had given
seemingly plateauing prevalence at around 1.48%, it did not take long for the
new figure of 1.68%. Some advocates are now running around claiming that
‘IT’ is now ‘1 child in 59’ (or even worse: 1 in 38 boys).
A study was conducted to examine the prevalence rates of ASD overall, AD,
and PDD-NOS in toddlers who were at risk for or who were already
experiencing a developmental delay. Participants were 2027 toddlers 17
through 36 months of age who received services through Early Steps.
Diagnostic procedures utilized second Edition (BDI-2; Newborg, 2005), the
Modified Checklist for Autism in Toddlers (M-CHAT; Charman et al., 2001),
criteria from the DSM-IV-TR (APA, 2000), and clinical judgment. A total of
611 toddlers of 2027 had a diagnosis of ASD; therefore, the prevalence of
7
8
ASD within the current sample was 30.14%. The prevalence of AD was
16.13% with 327 toddlers out of 2027 having an AD diagnosis. Lastly, a total
of 284 of 2027 had a diagnosis of PDD-NOS making the prevalence rate of
PDD-NOS in the current sample at 14.01%.
United States provided estimates of the prevalence of ASD and other

characteristics among children aged 8 years. ADDM surveillance was
conducted in two phases. The first phase consisted of screening and
abstracting comprehensive evaluations performed by professional providers in
the community. The second phase involved a review of all abstracted
evaluations by trained clinicians to determine ASD surveillance case
status. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR) diagnostic criteria was used. For 2010, the
overall prevalence of ASD among the ADDM sites was 14.7 per 1,000 (one in
68) children aged 8 years. Overall ASD prevalence estimates varied among
sites from 5.7 to 21.9 per 1,000 children aged 8 years. Approximately one in
42 boys and one in 189 girls living in the ADDM Network communities were
identified as having ASD (Maenner et al., 2021).
According to the Autism Society of Pakistan, there were more than 350,000
children who were suffering from this disease. It cannot be easily diagnosed
and requires clinical analysis (Khan et al., 2019). This specific study was
planned to evaluate childhood autism awareness among the medical
professionals of Pakistan in order to evaluate the prevalence of lack of
awareness regarding ASD so that a proper intervention plan can be developed
accordingly. This cross-sectional descriptive study was conducted by random
sampling method among 105 medical professionals in Pakistan during April
2020 for one month. Data was collected through an online survey by using a
self-administered questionnaire, accessing knowledge regarding Autism. Data
was analyzed using SPSS 23. Of the 105 participants, there were more females
than males. There was an evident lack of awareness regarding this disorder,
with 39 % being likely aware of autism, and 20% being moderately aware. Of
the ones aware, 28% were female and 33 % male. 41% claimed that they had
never been around someone who was suffering from Autism
8
9
Study investigators in China independently conducted a systematic literature

search of different databases, China National Knowledge Infrastructure,
Chinese biomedical literature service system, and Wan Fang. Forty-four
studies were included comprising 2,337,321 subjects of whom 46.66 % were
females. The mean age of subjects ranged from 1.6 to 8 years. Based on
diagnostic criteria the pooled prevalence of ASDs was 39.23 per 10,000;
specifically, the prevalence of autism was 10.18 per 10,000. Subgroup
analyses revealed significant difference in the prevalence of ASDs between
genders (72.77 per 10,000 in males vs. 16.45 per 10,000 in females) (Zhou et
al., 2020).
Using the Longitudinal Study of Australian Children (LSAC) data, prevalence

of parent-reported diagnosis of ASD and its relationship to demographic and
socio-economic status (SES) variables in Australia, as well as age of diagnosis
was estimated. Children were recruited in 2004 using a two-stage cluster
sampling design. In stage 1, postcodes were sampled (except for the most
remote) following stratification by state of residence and urban versus rural
status. In stage 2, children were sampled from the Australian Medicare
database, in which the majority of Australian children are enrolled. Soloff et
al., (2005) A total of 64% of the B cohort (n=5107) and 59% of the K cohort
(n=4983) were recruited into the study. PedsQL was the most frequently used
tool and the only tool in which reliability and validity were established for
ASD. Prevalence of autism spectrum disorder was 2.5% in the B cohort
compared to 1.5% in the K cohort.
The prevalence of ASD in Germany was estimated to be about 0.25% in 0- to

24-year-olds in 2009 (Bachmann et al., 2013). There were also concerns that
ASD may constitute a ‘fashionable’ diagnosis (Haker, 2014). Inpatient and
outpatient data of the German statutory health insurance company from the
years 2006 to 2012 was used for study. From 2006 to 2012, the prevalence of
autism spectrum disorder diagnoses in 0- to 24-year-olds increased from
0.22% to 0.38%. In insures with a first-time autism spectrum disorder
diagnosis in 2007, this diagnosis was carried on in all years through 2012 in
33.0%.
9
10
In 2002/2003, the National Epidemiologic Database for the Study of Autism in

Canada started capturing information on children diagnosed with autism in
different regions of the country. Based on data collected through 2008 in
Newfoundland and Labrador and 2010 in Prince Edward Island and
Southeastern Ontario ASD prevalence was estimated, among children 2–14
years of age. Significant increases in prevalence were detected for the overall
group of children 2–14 years of age in all regions, with an average annual
percentahange of 14.6 % in Newfoundland and Labrador; 9.7 %, in Prince
Edward Island; and 13.8 % in Southeastern Ontario (Ouellette-Kuntz et al.,
2014).
To determine the prevalence of autism spectrum disorder (ASD) in preschool

and school-age children in Spain a two-phase procedure was followed. The
screening phase was performed on a sample of 5555 children taking into
account parent and teacher information. The individual assessment included
the ADI-R, ADOS-2 and Wechsler scales. The estimated prevalence was
1.55% in preschoolers and 1.00% in school-age children. Between 1.84 and
2.59% of the children exhibited subclinical diagnosis. The male-to-female
ratio was around 4:1. Most of the children exhibited mild and moderate
nuclear symptoms, and the girls showed less severe communication problems.
Previous diagnosis was found in 62–71% of the children. Prevalence estimates
were close to the 1% international ratings and much higher than previous
national reports suggested (Morales-Hidalgo et al., 2018).
Centers for Disease Control and Prevention study reporting an estimated ASD
prevalence of 0.75% when based solely on health records but an estimate of
1.0% when based on education and health records combined. The first
population-based autism prevalence study in Korea targeted the entire
elementary school population of a South Korean community, using both a
general population sample and a group with a high probability of ASDs. The
target population was all 7- to 12-year-old children (N=55,266) in a South
Korean community. Autism Spectrum Screening Questionnaire was used for
systematic, multi-informant screening. The prevalence of ASDs was estimated
to be 2.64%, with 1.89%, in the general-population sample and 0.75% in the
high-probability group. ASD characteristics differed between the two groups:
10
11
the male-to-female ratios were 2.5:1 and 5.1:1 in the general population
sample (Kim et al., 2011).
To estimate of the prevalence of autism spectrum disorder (ASD) among

Omani children descriptive study was conducted from December 2011 to
December 2018. Data were retrieved from the three main autism diagnostic
centres in Oman and ASD diagnosis was made by (DSM-5). The prevalence
of ASD in the Omani population was estimated to be 1.4 per 10,000 children
in 2011, aged 0–14. A total of 1,705 ASD cases were identified with the
majority of cases being male (78.1%). The overall prevalence rate of ASD was
estimated at 20.35 per 10,000 children between 2012–2018. Boys were found
to have a 3.4-fold higher prevalence of ASD than girls (Al-Mamri et al.,
2019).
A study was conducted to estimate the prevalence of ASD in a large

representative community sample of the child population in Pisa (Italy). The
study protocol which was adopted is part of a wider project called ASDEU
(Autism Spectrum Disorders in European Union). The target population was
composed of 10 138 children between 7 and 9 years (51.6% males and 48.4%
females), living in the metropolitan area of Pisa. First, the number of certified
children with diagnosed ASD was verified by the ASDEU team. Second, a
Teacher Nomination form (TN) to identify children at risk for ASD was filled
in by teachers who joined the study and the Social Communication
Questionnaire (SCQ) was filled in by the parents of children identified as
positive. This population-based ASD prevalence study conducted in Italy so
far indicated a prevalence of ASD in children aged 7–9 years of about one in
87 (Narzisi et al., 2018).
In Saudi Arabia, the prevalence of autism was 18 per 10,000 children, (Al-
Sharbati et al., 2015) while in the United Arab Emirates, from a representative
random sample of three-year-old Emirati children, 29 per 10,000 children had
autism. In Libya, of 38,508 children who attended a paediatric clinic in
Tripoli, 128 children were autistic, thus giving a prevalence of one in 300 (Al-
Adawi et al., 2012). Furthermore, in Egypt and Tunisia, the autism frequency
rate among children with developmental disorders was documented as 33.6%
11
12
and 11.5%, respectively (Al-Mandhari et al., 2009). It appears that there was a

wide discrepancy in the magnitude of ASD, even among countries with similar
sociocultural characteristics; therefore, it is essential to discuss factors that
may have contributed to such variations (Zeglam et al., 2012).
In Israel, three epidemiological studies on ASD have been published. An

incidence of 0.1 % for the years 1989–1993 amongst children aged 0–5 years
(Davidovitch et al., 2001), of 0.019 % (Senecky et al., 2009) and of 0.12 %
(Gal et al., 2012) for children born in 1986, which had increased to 0.36 % for
children born in 2003. For children aged 6 and above, an ASD diagnosis is
made outside of the Maccabi Child Development Center, usually by a Maccabi
pediatric neurologist or child psychiatrist, who records the diagnosis on the
individual’s electronic file on Maccabi’s computer registry. Out of 423,524
children between the ages of 1–12 years, 2,187 had an ASD diagnosis and
2,034 children who had a definitive diagnosis of ASD. Thus the prevalence
was 4.8 per 1,000 (0.48 %). For the second prevalence calculation, in children
8 years of age in 2010, a figure of 6.5 per 1,000 children was obtained. a rate
of ASD prevalence for the 2010 calendar year in Israel of 0.48 % for children
1–12 years, which is higher than previously reported Israeli prevalence figures
(Gal et al., 2012).
Prevalence studies on autism spectrum disorders (ASD) have been carried out
in more than 15 countries since 1966, largely in the western hemisphere.
Estimates vary from 4.1 per 10,000 individuals in 1966 (UK) to as high as 113
per 10,000 (USA) individuals in 2014 according to region and time
(Elsabbagh et al., 2012). Specifically within Asia, estimates vary widely
across time and country (China: 0.003–0.17%, Japan: 0.011–0.21%, South
Korea: 1.89%) (Kim et al., 2011). Five studies in Japan have used an 18-
month health checklist. In China, five studies used the Chinese autism
behavior scale (Zhang and Ji, 2005). Population-based studies in Asia since
2000 establish a median observed prevalence of 13.9 per 10,000 individuals
(Elsabbagh et al., 2012)
India is the largest exception to the list of countries with an estimate of

prevalence of autism and supra threshold autistic traits in the general
12
13
population (Elsabbagh et al., 2012). The study included children aged 3–8

years attending different types of schools N = 11,849 children (mean age = 5.9,
39.5% females) were selected from various school types from three boroughs
in Kolkata, India. The school types included were government, private (18),
nongovernment organizations and 1 group of anganwadi centers. Written
responses were transcribed electronically, and statistical analysis was
performed using SPSS version 19. The weighted estimate of supra-threshold
SCQ scores was 3.54% (CI: 2.88–4.3%). The weighted prevalence estimate of
positive scores (for broader autism spectrum + ASD + autism) was 0.23%
(0.07–0.46%).
Studies on autism spectrum disorders (ASDs) have largely focused on

children in specific settings. This is a population-based prevalence study
conducted, across rural, urban, and tribal populations in India. A cross-
sectional two-phase study was conducted, children in the age group of 1–10
years of age across geographical regions representing rural, urban, and tribal
populations. The first phase (screening phase) and second phase (evaluation
phase). About 43 children out of a total of 28,070 children from rural, urban,
and tribal areas in the age group of 1–10 years were diagnosed as cases of
ASD yielding a prevalence of 0.15% majority were above age 4. The
prevalence of ASD was found to be highest in the rural area with 26 children
in the age group of 1–10 (Raina et al., 2017).
This study determined the prevalence of autism spectrum disorders in 201

(103 females and 98 males) siblings of children with autism spectrum
disorders. The mean age of siblings was 7.5 years. Siblings were screened
using Modified Checklist for Autism in Toddlers and Social Responsiveness
Scale, parent version. The concordance rate for autism among monozygotic
twins has been estimated to vary from 36% to 91% by the pair and 53% to
95% by proband, with no concordance among dizygotic twins, thus supporting
the genetic influence for autism. An epidemiologic survey of 207 autistic
families in the city of Utah showed the overall recurrence risk estimate to be
8.6%. Baby Siblings Research Consortium, however, showed a sibling risk of
18.7%. Thus the prevalence of ASD in the siblings in this study was 4.97%
(10 of 201 siblings) with a 95% confidence interval of 0.017 to 0.083. There
13
14
were 5 males and 5 females, giving a prevalence of 4.9% in female siblings

and 5.1% in males (Kumar et al., 2016).
In Bangladesh, a study has explored at the prevalence of ASD among rural

community children aged between 18-36 months. A cross sectional study was
conducted among the 5286 children aged between 18-36 months in a rural
community, using screening tool MCHAT, 04 children were diagnosed with
autism spectrum disorder (ASD). Prevalence of the ASD in rural community
was found 0.75/1000 children. Among the four ASD cases three were boys
and one was girl and age range was between 20- 30 months. Age specific
autism (18-36 months) in children is found higher in rural community of
Bangladesh (Akhtar et al., 2018).
A study was conducted to determine the prevalence of true ASD diagnoses in

children referred for diagnostic ASD evaluation, 348 children completed a
diagnostic autism evaluation. The mean age of the children evaluated was 6
years 7 months ± 3 years 5 months. Charts of all patients referred to a regional
autism center between April 2011 and August 2012 for suspicion of a possible
ASD were reviewed and demographic and clinical diagnoses abstracted. The
average age of initial ASD diagnosis has been reported at 5.7 years, although
studies have shown diagnostic stability for children diagnosed as early as 2
years of age (Johnson and Myers, 2007). This study included both children
who (1) had failed an autism screen (n = 287; either the Modified Checklist
for Autism in Toddlers or the Social Communication Questionnaire) and (2)
children who did not receive a screen or who passed the screen (n = 61)
(Robins et al., 2000). Only 214 of 348 patients evaluated (61%) received an
ASD diagnosis.
The DSM-5 states that “autism spectrum disorder is diagnosed four times
more often in males than in females. This 4:1 gender ratio was widely cited
and comes from work that calculated the mean male-to-female ratio from
population prevalence studies of ASD (Fombonne et al., 2009). ASD male-to-
female ratios show striking variability, ranging from 8:19 (Kopp et al., 1992)
to 2:1 (Bargiela et al., 2016). Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews was
14
15
followed. Investigation of ASD prevalence was done within a general

population sample. Diagnosis of ASD based on DSM-5, DSM-IV-TR, DSM-
IV, or International Classification of Diseases, Tenth Revision (ICD-10)
criteria. Age range of sample was from 0 to 18 years. Fifty-four studies were
analyzed, with 13,784,284 participants, of whom 53,712 had ASD (43,972
boys and 9,740 girls). The true male-to-female ratio was not 4:1, as is often
assumed; rather, it is closer to 3:1.
A study was conducted in USA on national and state prevalence of adults 18–
84 years living with ASD using simulation in conjunction with Bayesian
hierarchal models. Unpublished ASD prevalence data from NSCH (2016–
2018) was used, published ASD population mortality rates, 1999–2017 U.S.
mortality rates by state, age, and sex, and 2017 population to develop an
estimator of ASD prevalence and cases by state and sex, and nationally for
2017. In 2017, it was estimated that approximately 2.21% (95% simulation
interval (SI) 1.95%, 2.45%) or 5,437,988 U.S. adults aged 18 and older have
ASD, with state prevalence ranging from 1.97% (95% SI 1.55%, 2.45%) in
Louisiana to 2.42% (95% SI 1.93%, 2.99%) in Massachusetts. Overall, they
estimated that 1 in 45 adults (95% SI, 41, 51), ages 18–84 years, were living
with ASD (Dietz et al., 2020).
Posphatase and tensin homologue (PTEN) is a cancer suppressor gene

(Veleva-Rotse et al., 2014). Research indicated possible increased rates of
developmental delay and autism spectrum disorder (ASD) for people with
germline mutations affecting PTEN. Whilst autism spectrum disorder (ASD)
was not a listed criterion for PHTS, (uxbaum et al., 2007). Two types of
studies were identified: those in which participants were recruited/included on
the basis of having an identified PTEN mutation or PTEN-related condition,
(group A); those in which participants were selected on the basis of some
other factor (e.g. macrocephaly) (group b). Existing research suggested
approximately 25% of people with constitutional PTEN mutations may meet
criteria for or have characteristics of ASD.
ASD prevalence estimates have increased from 6.7 (one in 150) to 18.5 (one
in 54) per 1,000 children aged 8 years at ADDM Network sites in surveillance
year 2016 (Maenner et al., 2016). No overall difference in ASD prevalence
15
16
between non-Hispanic White (White) and non-Hispanic Black (Black)

children aged 8 years according to 2016 ADDM data. Prevalence was
calculated as the number of children with ASD divided by the total number of
children in the defined population or group per 1,000 children. Prevalence was
calculated overall, by sex, and by race and ethnicity for White, Black,
Hispanic. The overall ASD prevalence per 1,000 children aged 8 years was
23.0 and ranged from 16.5 in Missouri to 38.9 in California. The overall male-
to-female prevalence ratio was 4.2, and site-specific ratios ranged from 3.3 to
5.2.
Over the past decade, the racial/ethnic disparities have persisted but have
narrowed (Xu et al., 2016). However, it remained unknown how racial/ethnic
disparities have changed over time. The National Health Interview Survey
collected data on a wide range of health-related topics through in-person
household interviews. Race/ethnicity for this study was self-reported. In this
nationally representative survey of US children and adolescents aged 3 to 17
years, 1330 of the 52 550 eligible individuals (2.53%) had been diagnosed
with ASD between 2014 and 2019. The overall weighted prevalence was
2.49%. The racial/ethnic disparities in ASD were complex and reflect
multiple levels of inequities which range from individual etiologic factors,
non-etiologic factors to environmental etiologic factor (Parsons et al., 2014).
To estimate the prevalence of ASD in a representative school sample of the

province of Tarragona, Spain, the study included a screening procedure
through parents (N = 3727) and teachers (N = 6894), and an individual
assessment of children at risk and a comparison group (N = 781). The overall
estimated prevalence in the sample was 1.53%. A total of 3.31% of the
children presented subclinical characteristics of autism spectrum disorder.
Girls showed a significantly lower estimated prevalence in all the
conditions. Severity profiles were distributed as 46% mild, 47% moderate and
7% severe. The results confirmed a high prevalence of autism spectrum
disorder in the province, suggesting a current under-diagnosis in public health
services (Morales et al., 2021).
16
17
The estimated prevalence of ASD in a population-based sample comprising

children aged 3–12 years (N = 74,252) in Shanghai, included a high-risk group
sampled from special education schools and a low-risk group randomly
sampled from general schools. Social Communication Questionnaire for
participating children was filled by their teachers and parents. ASD was
identified based on DSM-5 criteria, 711 children as being at-risk for ASD, of
which 203 were identified as ASD cases. The prevalence of ASD was 8.3 per
10,000 (Jin et al., 2018).
A study was conducted from July 2014 to December 2016 to obtain the first
national estimate of the prevalence of autism spectrum disorder (ASD) in
Chinese children of 6 to 12-year-old. The Modified Chinese Autism Spectrum
Rating Scale was used for the screening process. Of the target population of
142,086 children, 88.5% (n = 125,806) participated in the study. A total of 363
children were confirmed as having ASD. The observed ASD prevalence rate
was 0.29% for the overall population. The prevalence was significantly higher
in boys than in girls (0.95%, versus 0.30%). Of the 363 confirmed ASD cases,
43.3% were newly diagnosed, and most of those (90.4%) were attending
regular schools and 68.8% of the children with ASD had at least one
neuropsychiatric comorbidity (Zhou et al., 2020).
The prevalence of autism/ASD among the preschool-age children (1-5 years

old) and school-age children (6-16 years old) along with the gender
differences was studied in the capital city of Oslo, Norway from 2012 to 2016.
The raw data consisted of Oslo’s children population of 1-16 years old along
with the ones who were registered to be diagnosed with Autism/ ASD between
the years 2012-2016. In 2016 the results revealed that 1 in 349 males and 1 in
1594 females between the ages of 1-5 years old had Autism/ASD and 1 among
157 males and 1 among 544 females had autism/ASD between the ages of 6-
16 years (Özerk et al., 2020).
ASD prevalence was estimated in 7–9 year-old children in 2015 using data

from three nation-wide health registry systems (Denmark, Finland, Iceland)
and two French population-based regional registries. In Denmark the study
included children who were 7–9 years of age between 2013 and 2015. For
17
18
Finland, information was gathered on all children with an ASD diagnoses

before 31 December 2015. Each site worked independently and estimated
prevalence of ASD following a common study protocol. Prevalence ranged
from 0.48% in South-East France to 3.13% in Iceland (South-West France:
0.73%, Finland: 0.77%, Denmark: 1.26%). Male/female ratios ranged from 3.3
in Finland to 5.4 in South-West France. Between 12% (Denmark) and 39%
(South-West France) of cases were diagnosed with intellectual disability
(Delobel-Ayoub et al., 2020).
Register-based prevalence rates of childhood autism (CA) and other autism

spectrum disorders (ASD) were calculated among children aged 7 years old of
2003, living in four counties in France. The proportion of children presenting
comorbidities was reported. About 1123 children with ASD were recorded
(M/F ratio: 4.1), representing an overall prevalence rate of 36.5/10,000
children: 8.8/10,000 for CA, 25.9/10,000 for other ASD. ASD prevalence
significantly increased during the period under study. The proportion of
children with an intellectual disability was 47.3 %, all other comorbidities
were present in less than 5 % of the cases (Van et al., 2015).
A study was conducted to assess the prevalence of ASD in children aged 0–16
years, inhabitants of West Pomeranian and Pomeranian regions. There were
921 participants (748 males and 173 females) and 1593 participants (1290
males and 303 females) with ASD from West Pomeranian and Pomeranian
regions, respectively. In West Pomeranian, the observation period was from
January 2010 to March 2014. The estimates were based on the government
registries, whereas data were obtained from Provincial Disability Services
Commissions. In the West Pomeranian Region, the prevalence of ASD was
found to be 32/10 000 children. The highest prevalence in this region, that is
53/10 000 in 4- to 7- year-old children was observed. Autism spectrum
disorders were 4-fold more prevalent in males than females (Skonieczna-
Żydecka et al., 2017).
A cross-sectional study examines the prevalence of Autism spectrum disorder

(ASD) in toddlers in nurseries in Beirut and Mount-Lebanon. The prevalence
of pervasive developmental disorders was found to be 1 % in adolescents in
18
19
Beirut (Maalouf et al., 2015). The objective of this study was to assess the
prevalence of autism spectrum disorder in toddlers aged between 18 and 30
months in nurseries in Lebanon using a screening instrument. The final sample
included 998 toddlers with expanded age range (16–48 months) from 177
nurseries. The Modified Checklist for Autism in Toddlers (MCHAT) for
screening, and a self-administered questionnaire (associated factors) was sent
to parents. ASD prevalence was 1 in 66 children (comparable to US). Ratios
were: male/female: 1.05; Beirut/ Mount-Lebanon: 1.2.
Parents of children with autism spectrum disorder appear to experience high

levels of psychological distress, yet little is known about the prevalence of
psychological disorders in this population. The following variables were
extracted: year of publication, sample size, age of parents, sex of parents, age
of children, sex of children, country of publication, diagnostic measure for
ASD. The median meta-analytic proportions were 31% for depressive
disorders, 33% for anxiety disorders, 10% for obsessive-compulsive disorder,
4% for personality disorders, 2% for alcohol and substance use disorders and
1% for schizophrenia spectrum disorders (Schnabel et al., 2020).
Individuals with ASD often present co-morbid psychiatric disorders. Hossain

et al., (2020) reported two studies estimating the prevalence of at least one
comorbid psychiatric disorder at 54.8% and up to 94%. Individuals with ASD
were more likely to experience somatic co-morbidities such as epilepsy (Lai et
al., 2019) gastro-intestinal (GI) disorders or sight/hearing impairments. A
systematic literature review (SLR) was conducted in 2019 to evaluate the
prevalence of ASD in children and adolescents (from 2 to <18 years old) in
EU-4 (France, Germany, Spain, and Italy) plus the UK, and the US. This SLR
focused on nine co-morbidities of interest: ADHD, anxiety, depressive
disorders, epilepsy, Intellectual Disability (ID), sleep disorders, sight/hearing
impairment/loss and GI problems (Tye et al., 2018). Thirteen studies on
prevalence of ASD and 33 on prevalence of co-morbidities were included.
Prevalence of ASD was 1.70 and 1.85% in US children aged 4 and 8 years
respectively, while prevalence in Europe ranged between 0.38 and 1.55%.
19
20
The literature from 2020 on the prevalence of epilepsy in autistic individuals

was systematically reviewed. The updated pooled prevalence of epilepsy in
autistic individuals was 10% out of 66 studies. The respective prevalence
estimate of epilepsy was 19% in the clinical sample-based cross-sectional
study, 7% in the cohort study, and 9% in the population-based cross-sectional
study. The pooled prevalence of epilepsy was 7% in autistic children and 19%
in autistic adults. The adolescence group and the pre-school group were
positively associated with the prevalence of epilepsy. About 1/10 autistic
individuals co-occurred with epilepsy, which was common in the clinical
setting, adolescents, adults, females, or patients with intellectual disability
(Liu et al., 2022).
About 70% of people with ASD may have a comorbid psychiatric disorder and
about 40% have two or more comorbid psychiatric disorders (American
Psychological Association, 2013). A recent meta-analysis (Hollocks et al.,
2018) estimated a combined prevalence of 27% to 42% for any anxiety
disorder, and from 23% to 37% for depressive disorders. Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al.,
2009) was used as a guideline. An electronic search was conducted from 2000
to 2016 in four databases. The average age of the whole sample was equal or
greater than 18 years. The search strategy included terms relating to all
psychiatric disorders as they are classified in the standard classifications
(DSM-5). A total of 47 studies were included. Results showed that attention
deficit and hyperactivity disorder is the most prevalent psychiatric disorder in
adults with ASD. Mood and anxiety disorders are also very frequent among
this population
The rates of co-existing neurodevelopmental disorders (NDD) in a total

population sample in Japan, to determine whether there was a true increase in
ASD prevalence by estimating the cumulative incidence of ASD annually, and
to examine the rates of co-existing neurodevelopmental disorders (NDD). All
5-year-old children in the catchment area underwent the screening annually
from the year 2013–2016. 559 children underwent the assessment with 87
children receiving an ASD diagnosis. The cumulative incidence of ASD up to
5 years of age for the total study years was 1.31%. Only 11.5% of children had
20
21
ASD alone; the remaining 88.5% were found to have at least one co-existing
NDD (Saito et al., 2020).
Individuals with autism spectrum disorder (ASD) or attention-deficit

hyperactivity disorder (ADHD) may have unhealthy bodyweight. Databases
were searched from inception until June 2020. A total of 95 studies were
included in the meta-analysis. The pooled estimates of the prevalence of
obesity, overweight and underweight were 21.8%, 19.8% and 6.4% in
individuals with ASD and 14.7%, 20.9% and 4.0% in individuals with
ADHD. An increasing trend in the prevalence of unhealthy weight was
observed from children aged 2 to 5 years to adults with ASD (obesity: from
16.7% to 31.3%, overweight: from 16.2% to 27.2%, underweight from 5.3%
to 8.6%) and from children aged 6 to 12 years to adults with ADHD (obesity:
from 13.5% to 19.3%, overweight: from 18.8% to 31.2%) (Li et al., 2020).
Prevalence of obesity in Autism Spectrum Disorder (ASD) has been reported

to be higher than in the general population. A cross-sectional study was
performed at the Child Development Center in Malaysia Medical Center on
151 ASD children aged 2–18 years. Anthropometric and demographic
information were obtained and parents completed three questionnaires. The
prevalence of overweight was 11.3% and the prevalence of obesity was
21.9%. The overweight/obese ASD children's median age was higher at 8.5
years compared to the normal/underweight group of 6.33 years. The
prevalence of obesity and overweight was high among Malaysian ASD
children and adolescents (Kamal et al., 2019).
The prevalence and incidence of early-onset dementia in individuals with ASD

was examined during 2008–2012. Participants were 30–64 year-old adults
who were diagnosed either with ASD only or ASD+ID. The 5-year prevalence
of dementia was 4.04% among adults with ASD only, and 5.22% for those
with ASD and co-occurring ID. In conclusion, adults with ASD under the age
of 65 were approximately 2.6 times more likely to be diagnosed with dementia
compared to the general population in our study (Vivanti et al., 2021).
Prevalence of feeding problems detected by speech therapists and

psychologists was higher for the ASD group than for the comparison group,
21
22
with the ASD group showing more food selectivity by texture (23.1% vs.
7.1%), more food selectivity by type (24.4% vs. 11.8%), more new food
refusal (10.3% vs. 0%), and more food overstuffing (14.1% vs. 3.5%) (Collins
et al., 2003). After applying the criteria for determining whether the child
chart represented the ASD or non-ASD LD group, there were 128 in the ASD
group and 143 in the LD group. More than 50% of children with ASD exhibit
limited food acceptance (Schreck et al., 2014).
The most common eating disorders (EDs) in young adults are anorexia
nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED)
(Dahlgren et al., 2017), and AN and avoidant/restrictive food intake disorder
(ARFID) are the most frequent in adolescents (Nicely et al., 2014). In young
females, ED prevalence is especially high, ranging from 0.3 to 1% of the total
population (Hoek, 2006). The data of 131 children with FEDs from The
Japanese Pediatric EDs was taken with AN (n = 92) or ARFID (n = 32) from a
prospective multicenter cohort study using the Autism Spectrum Quotient
Children’s version (AQC) and Children’s Eating Attitudes Test (ChEAT26).
The J-PED study included 11 medical institutions throughout Japan. All
patients were assessed through direct observation and interview, and diagnoses
were guided by the DSM-5. ASD prevalence was high in both AN and ARFID
(16.3 and 12.5%, respectively).
A prominent set of behavioral/psychological features associated with FXS are

characteristics associated with ASD. A systematic literature search identified
papers (34) reporting ASD prevalence and/or symptomatology in females with
FXS. Twenty-eight papers reported prevalence data for ASD in females with
FXS. Reported prevalence ranged from 0 to 66%. Weighted average
prevalence of ASD among female participants with FXS was 17%. Whilst up
to 60% of males with fragile X syndrome (FXS) met criteria for autism
spectrum disorder (ASD) (Marlborough et al., 2021).
Anxiety disorders affect ~15–20% of youths without neurodevelopmental

disorders, with persons having autism spectrum disorder (ASD) and fragile X
syndrome (FXS) at elevated risk for anxiety disorders (Beesdo et al., 2011).
Only one diagnostic study of anxiety has been conducted in FXS (Cordeiro
22
23
et al., 2011). Participants were males with non-syndromic ASD (n=20) or

FXS (n=31). The samples were matched on chronological age ranging from 13
to 24 years of age. Overall, 51.6% of the FXS adolescents met criteria for any
anxiety disorder, with 12.9% meeting criteria for multiple anxiety disorders,
50.0% of adolescents with ASD met criteria for any anxiety disorder, and
30.0% met criteria for multiple anxiety disorders (Salum et al., 2013).
Stereotypies were frequently reported in people with autism spectrum disorder

(ASD) but remain one of the less explained phenomena. Through a systematic
review and a meta-analysis, the prevalence of motor stereotypies in ASD was
studied along with factors that influence this prevalence. Thirty-seven studies
were included and the median prevalence of motor stereotypies in ASD was
51.8%, ranging from 21.9% to 97.5%. The most frequent determinants
associated with a higher number of stereotypies in ASD were a younger age,
lower intelligence quotient, and a greater severity of ASD. Moreover, gender
did not seem to influence the prevalence of stereotypies (Melo et al., 2020).
A number of studies have indicated that students with disabilities are at

greater risk for experiencing bullying than typically developing students (Bear
et al., 2015). Systematic database and literature review identified 34 relevant
studies. Pooled prevalence estimates for victimization, perpetration, and
perpetration-victimization in general were 67%, 29%, and 14%, respectively.
A recent meta-analysis of bullying prevalence studies in students with ASD
reported the prevalence of bullying involvement as victims, bullies, and bully-
victims as 44%, 10%, and 16%, respectively (Maïano et al., 2016).
ASD has a number of psychopathological correlates, which further reduce the

quality of life in affected individuals (Steensel et al., 2011). Up to 50% of
children have been bullied by their siblings and up to 40% have bullied their
siblings (Wolke et al., 2015). The risk of being bullied by peers in children
with ASD may be mirrored in vulnerability to sibling bullying (Hebron et
al., 2015). In this study, data collected (age 11 years) were analyzed. Twins
and those who did not have any siblings were excluded. Here were 475
children with ASD and 13,702 children without ASD aged 11 years. Children
23
24
with ASD were more likely to be bullied by their siblings compared to those
without ASD.
Researches have indicated that autism was over-represented among inpatients

in forensic high secure hospitals in England. The study was conducted to
assess the feasibility of estimating the prevalence of autism without an
intellectual disability in medium secure units (MSU). Male inpatients on three
MSU wards were approached to participate in the study. Out of 30, 12 males
participated. After ruling out an intellectual disability using the Schonell
Graded Work Reading Test, these individuals were screened for autism using
the AQ, and completed the EQ. The results indicated that this group is over-
represented within medium secure forensic psychiatric units (Kalpana et al.,
2021).
Pain is a leading contributor to the global morbidity and disability burden.

Pediatric pain is especially problematic, as it may impede healthful
development into and throughout adulthood (Noel et al., 2016). Data was
collected from the 2016-2017 National Survey of Children’s Health, the
overall weighted response rate was 40.7% for 2016 and 37.4% for 2017. The
prevalence (weighted estimates) of pain was 8.2% for children without ASD,
15.6% for children with ASD, and 19.9% for children with ASD and at least 1
developmental comorbidity.
A century ago, Bleuler considered “autism” to be one of the four core

symptoms of schizophrenia (Askok et al., 2012). The population prevalence of
schizophrenia was estimated to be one percent (Bradley et al., 2011) and ASD
may present a risk factor for the development of schizophrenia (Nylander et
al., 2008). Studies were identified through searches of three large electronic
databases. The point prevalence rates for ALTs ranged from 9.6% to 61%,
whilst the prevalence rates for diagnosed ASD ranged from < 1% to 52%
across outpatient and inpatient populations. This suggests that prevalence rates
of ALTs and ASD in psychosis populations are much higher than in the
general population.
Autism spectrum disorder (ASD) phenomenology was reported to be more

common in individuals with some genetic syndromes than in the general
24
25
population. Syndromes reported as most likely to be associated with ASD was

studied. Screening and extraction of papers was done, that had ASD
prevalence data for ten or more people within a genetic syndrome. 168 papers
reporting the prevalence of ASD phenomenology was identified. Quality-
weighted effect prevalence estimates of ASD phenomenology were
established for Rett's syndrome (female individuals only 61%), Cohen's
syndrome (54%) , tuberous sclerosis complex (36%), Angelman's
syndrome (34%), fragile X syndrome (male individuals only 30%; mixed sex
22%), neurofibromatosis type 1 (18%), Down's syndrome (16%), Noonan's
syndrome (15%). In all syndromes, odds ratios showed ASD phenomenology
to be significantly more likely than in the general population (Richards et al.,
2015).
Autism Spectrum Disorder (ASD) and Obsessive Compulsive Disorder (OCD)

commonly co-occur in children and adolescents (C&A). Electronic searches
were carried out on 3 databases. A total of 15 studies were included in the
systematic review. Seven of these studies directly compared the prevalence of
ASD traits (measured by questionnaires) or diagnosis in OCD to a control
group or normative data, with all studies reporting a significant elevation in
ASD trait scores and diagnosis in OCD. Ten of the studies reported on the
correlation between ASD trait severity and OCD severity. Four studies
identified a significant correlation between ASD and OCD total scores or
specified subscales (Claire et al., 2021).
Autism spectrum disorders (ASD) often co-occur with intellectual disability

(ID) and were associated with poorer psychosocial and family-related
outcomes than ID alone. This study in 2016 examined the prevalence,
stability, and characteristics of ASD estimated in 2,208 children with ASD and
ID identified through the South Carolina Autism and Developmental
Disabilities Network. The prevalence of ASD in ID was 18.04%, relative to
ASD rates of 0.60%–1.11% reported in the general South Carolina population.
Compared to children with ASD alone, those with comorbid ID exhibited
increased symptom severity and distinct DSM-IV-TR profiles (Tonnsen et al.,
2016).
25
26
It was well known that very preterm and extremely preterm infants carry a
high risk of long-term neurodevelopmental morbidities. (Ancel et al., 2011).
Evidence was emerging that prematurity and being of low birth weight are risk
factors for later development of autism spectrum disorder (ASD) (Cheong et
al., 2017). The databases were searched from inception until May 2017.
Researchers in a total of 18 studies (3366 preterm infants) used ASD
diagnostic tools. The median gestation, birth weight, and age at assessment
were 28.0 weeks (range: 25.1–31.3 weeks), 1055 g (range: 719–1565 g), and
5.7 years (range: 1.5–21 years), respectively. Meta-analysis revealed that the
overall prevalence rate for ASD was 7%.
Both preterm and post-term births have been linked to elevated risk of ASD. A
recent meta-analysis identified 14 original research articles investigating the
association between post-term birth and risk of ASD (D’Onofrio et al., 2013)
of these, seven reported null findings, six reported a positive association
(Gardener et al., 2011). The relationship between gestational age at birth and
ASD without ID would be different from that between gestational age at birth
and ASD with ID, and these relationships might be different in males and
females. Register-linkage cohort study of the total child population aged 0–17
years residing in Stockholm County, Sweden, who were born between 1984
and 2007. The last follow-up date in the study period was December 31, 2011.
The study sample included 480 728 individuals. A total of 10 025 (2.1%)
persons were diagnosed with ASD; of these, 2368 (23.6%) and 7657 (76.4%)
were diagnosed with and without co-occurring ID, respectively.
For the first time, the burden of ASDs has been estimated for the Global
Burden of Disease Study 2010 (GBD 2010). The aims of this study were to
develop global and regional prevalence models and estimate the global burden
of disease of ASDs. Data was pooled using a Bayesian meta-regression
approach. Burden was calculated in terms of years lived with disability
(YLDs) and disability-adjusted life-years (DALYs), which are reported here
by world region for 1990 and 2010. In 2010 there were an estimated 52
million cases of ASDs, equating to a prevalence of 7.6 per 1000 or one in 132
persons. Globally, autistic disorders accounted for more than 58 DALYs per
26
27
100 000 population and other ASDs accounted for 53 DALYs per 100 000
(Baxter et al., 2015).
There was growing consensus that the worldwide prevalence of ASD was
around 1%, making it one of the most common developmental disorders
(Schendel et al., 2012). A key diagnostic challenge was that ASD has no
pathognomonic features (Yates and Le Couteur, 2009). That is, no single
feature on its own will confirm or rule out ASD. Data on the incidence,
prevalence, and impact of ASD in South Africa are almost entirely lacking. No
epidemiological studies of ASD have been conducted in the country. UCT has
recently established a Centre for Autism Research in Africa. The goal of the
Centre is to gather an interdisciplinary team of researchers to drive work in
this field. Most ASD research to date has used Caucasian families from high-
income communities (Hilton et al., 2010). The Centre is therefore prioritizing
the establishment of reliable and valid tools for screening and diagnosis in our
context, and developing local expertise in using these tools.
27
31
MATERIALS AND METHODS

The present study was conducted in special education institutes and Autism
centres of Sheikhupura by collection of information on structured data
collection form. I choose a survey research design because it best served to
answer the questions and the purposes of the study. The survey research is one
in which a group of people or items is studied by collecting and analyzing data
from only a few people or items considered to be representative of the entire
group. A survey assesses a public opinion or individual characteristics by the
use of questionnaire and sampling methods.
3.1 Experimental design
The present study was conducted from special education institutes and
Autism centres of Sheikhupura, on a sample of 100 children having Autism
Spectrum Disorder.
3.2 Duration of study
The duration of study was January, 2022 to June, 2022.
3.3 Study population
For some studies, the population may be small enough to warrant the inclusion
of all of them in the study. But a study may entail a large population which
cannot all be studied. That portion of the population that is studied is called a
sample of the population. A sample in this study is, therefore, a smaller group
of a few elements drawn through a definite procedure from an accessible
population. The elements making up this sample are those that are actually
studied. The research sample of children aged 3 to 17 years was subject to a
simple random sampling procedure. A pre-defined questionnaire was filled out
by the teachers of the students, covering gender, age, group, socioeconomic
status, residence, parent’s relationship, partnership status of parents and
Childhood Autism Rating Scale (CARS). The correctness and completeness of
all surveys were verified.
3.4 Data collection
28
31
The main outcome of the study was the prevalence rate of Autism Spectrum
Disorder among children in special education institutes and Autism centres of
Sheikhupura, assessed by the survey sample.
Data was gathered on independent variables like socioeconomic characteristics

and prior medical history.
3.5 Instrument for data collection
A questionnaire was designed as one of the data collection instrument for this
study. The primary school music teachers were interviewed. The interview
questions were aimed at eliciting relevant information concerning prevalence
of Autism spectrum disorder in children. A questionnaire (see Annexure) was
designed used in the study.
3.6 Questionnaire
Information was gathered by a standard pre-constructed questionnaire

containing a socio-demographic history and variables such as age, gender,
residence, parent’s relationship, partnership status of parents and a Childhood
Autism Rating Scale (CARS) containing 15 items (e.g., emotional response,
body use, activity level, etc).
3.7 Childhood Autism Rating Scale: Second Edition (CARS-2)
CARS test was designed in 2010 in two different age ranges of 0-6 years old
and over 6 years old, as a questionnaire with a duration of 15 minutes. This
test has 75% content validity, 76% reliability, its sensitivity is 81%, and its
specificity is 87%.
3.8 Validation of the questionnaire
The questionnaire designed for the study was subjected to a validation process
for face and content validity. Face and content validity have been defined as
following:
● Face validity is the idea that a test should appear superficially to test
what it is supposed to test; and
● Content validity is the notion that a test should sample the range of
behavior represented by the theoretical concept being tested.
29
31
The experts went through the research questions and the questionnaire
carefully to ascertain the appropriateness and adequacy of it.
This was done in order to see:
● How the subject will react to the questionnaire;
● whether the items are clear enough and easily understood;
● whether there is the need to include more items in certain areas; or
● whether there are some items to which they would not like to respond;
as well as
● to determine the workability of the proposed method of data analysis

for the study.
3.9 Ethical consideration
As children aged 3 to 17 years were participating in the trial, the informed

permission of the institute was thus requested. The Lahore College for Women
University’s review board received the ethical consent for the project.
3.10 Method of data analysis
The data collected from the field was analyzed statistically by using SPSS
version 26. Chi square was applied on study subjects. Chi-Square technique
was used to test the association between two qualitative parameters. P-value
<0.05 was considered as significant, P-value at <0.01 was considered as
highly significant and P-value at >0.05 was considered as insignificant.
30
32
RESULTS
Our survey of various special education institutes and autism centers revealed
a final sample of 100 children whose teachers and parents/guardians
volunteered to take part in the study, who were identified by the psychologist
of respective institution. The results are given below:
4.1 Prevalence of ASD in children by Age
In a sample of 100 children the age range was 3-17 years. The age of 100
children divided into groups of 3 years each. The prevalence of autism in
children with age range of 3-5 years is 14%, the prevalence is 29% in children
with age range of 6-8 years, similarly the prevalence percentages for age range
of (9-11 years, 12-14 years, 15-17 years) are (25%, 17% and 15%)
respectively.
4.1.1 Association of Age of Autistic children with parameters of CARS

test
The relationship of age of autistic children with 15 parameters of the

Childhood Autism Rating Scale is given below:
The p value for some of the CARS parameters like “emotional response” is
0.02, for “taste, smell and touch response and use” the value is 0.047, for
“general impressions” the value is 0.009 and all these p values are smaller than
the alpha value (0.05), so the results (shown in figures and tables below) are
significant for these variables , hence these variables are associated with the
age of the child with ASD, while for other variables like, “relating to people”,
“imitation” , “body use”, “object use”, “adaptation to change”, “listening
response”, “fear and nervousness”, “verbal communication”, “non-verbal
communication”, “activity level”, “level of consistency of intellectual
response”, the p values are (0.80, 2.52, 0.74, 0.18, 0.80, 0.58, 0.43, 0.44, 0.13,
0.41, and 0.87) respectively and all these values are insignificant and are
independent of the age of the child with ASD.
Table 4.1: Chi square table; shows the association of Age with
Emotional response in children with ASD.
31
32
Chi-Square Tests
Asymptotic
Significance (2-
Value df sided)
Pearson Chi-Square 24.788a 8 .002
Likelihood Ratio 27.129 8 .001
Linear-by-Linear 11.930 1 .001
Association
Figure 4.1: Bar chart shows the association of age with general impressions of
children with ASD.
Table 4.1.1: Chi square table, shows the association of age with taste, smell
and touch response and use by children with ASD.
32
32
Chi-Square Tests
Asymptotic
Significance (2-
Value df sided)
Linear-by-Linear 11.891 1 .001
Association
N of Valid Cases 100
4.2 Prevalence of ASD in children by Residence
33
32
In a sample of 100 children, 72% prevalence of autism was found in children

of urban areas and 28% prevalence of autism was observed in children belong
to rural areas.
4.2.1 Association of Residence of Autistic children with parameters of

CARS test
The association of residence of children with ASD with 15 parameters of the

The p values for the mentioned CARS test parameters like “relating to
people”, “imitation”, “emotional response”, “object use”, “body use”, “visual
response”, “taste , smell and touch response and use”, “verbal and non-verbal
communication”, “level and consistency of intellectual response”, “general
impressions”, and “adaptation to change” are (0.51, 0.28, 0.38, 0.93, 0.32,
0.32, 0.29, 0.47, 0.79, 0.10 and 0.80) respectively, all these p values are
greater than the alpha value (0.05) hence , the results shows that residence and
these factors are independent of each other , while p values for some of the
CARS parameters like “listening response” is 0.05, for “fear or nervousness”
the value is 0.01, and for “activity level” the value is 0.01, all these p values
for the certain parameters showed significant results (shown in figures and
tables) hence these factors are associated with the residence of the children
with ASD.
Table 4.2: Chi-square test table; shows the association of residence with
listening response of children with ASD.
Chi-Square Tests
34
32
Asymptotic
Significance (2-
Value df sided)
Figure 4.2: Bar chart representing the association of residence with fear and
nervousness in children with ASD.
Table 4.2.1: Chi square test table; shows the association of residence with
activity level of children with ASD.
Chi-Square Tests
Asymptotic
Significance (2-
Value df sided)
35
32

4.3 Prevalence of ASD in children by Socioeconomic status
In a sample of 100 children 19% prevalence of autism was observed in

children of upper class families, 77 % prevalence of autism was observed in
children of middle class families, and 4% prevalence of autism in children of
lower class families.
4.3.1 Association of Socioeconomic status of Autistic children with

parameters of CARS test
36
32
The association of socioeconomic status of autistic children with 15

parameters of the Childhood Autism Rating Scale is given below:
The p values for maximum no of CARS parameters like “relating to people”,

“imitation”, “emotional response”, “body use”, “visual response”, “taste ,
smell and touch response and use”, “verbal communication”, “non-verbal
communication”, “level and consistency of intellectual response”, “general
impressions”, “body use”, “adaptation to change”, “listening response”, and
“activity level” are (0.91, 0.55, 0.07, 0.10, 0.66, 0.38, 0.37, 0.54, 0.61, 0.93,
0.77, 0.52 and 0.43) respectively, all these values are greater than the alpha
value (0.05) hence , socioeconomic status and these factors are independent of
each other , while p values for some of the CARS parameters like “object
use” is 0.05 and for “fear or nervousness” the value is 0.03, these values
showed significant results (shown in table and graph) hence these factors are
associated with the socioeconomic status of children with ASD.
Table 4.3: Chi square table; shows the association of socioeconomic status
with object use in children with ASD.
Chi-Square Tests
Asymptotic
Significance (2-
Value Df sided)
37
32
Figure 4.3: Bar chart representing the association of socioeconomic status

with fear and nervousness in children with ASD.
4.4 Prevalence of ASD in children by Gender
In a sample of 100 children 50% prevalence of autism was observed in males

and 50% prevalence of autism was observed in females.
4.4.1 Association of Gender of Autistic children with parameters of CARS

test
The association of gender of autistic children with 15 parameters of the

38
32
The p values for the following parameters of CARS test like, “imitation”,
“emotional response” , “body use”, “object use”, “non-verbal
communication”, “level and consistency of intellectual response”, “listening
response”, “visual response”, and “fear or nervousness” are (0.44, 0.12, 0.38,
0.38, 0.83, 0.29, 0.93, 0.22, and 0.72) respectively, and all these values are
greater than the alpha value (0.05) hence , gender of the autistic children and
these factors are independent of each other , and the p values for some of the
parameters of CARS test like for “relating to people” the value is 0.009, for
“taste , smell and touch response and use” the value is 0.01, for “verbal
communication” the value is 0.04, for “adaptation to change” the value is 0.02,
for “activity level” the value is 0.03, and for “general impressions” the value
is 0.002, all these values showed significant results (shown in tables and
graphs below) hence these factors are associated with the gender of children
with ASD.
Table 4.4: Chi square table; shows the association of gender and the level of
relatedness of children with ASD with other people.
Chi-Square Tests
Asymptotic
Significance (2-
Value Df sided)
39
32
Figure 4.4: Bar chart representing the association of gender with taste , smell
and touch response and use in children with ASD.
Table 4.4.1: Chi square table; shows the association of gender with verbal
communication in children with ASD.
Chi-Square Tests
Asymptotic
Significance (2-
Value df sided)
40
32
Figure 4.4.1: Bar chart representing the association of gender with adaptation
to change by children with ASD.
Table 4.4.2: Chi square table; shows the association of gender with activity
level of children with ASD.
Chi-Square Tests
Asymptotic
Significance (2-
Value df sided)
41
32
Figure 4.4.2: Bar chart representing the association of gender with general
impressions of children with ASD.
4.5 Prevalence of ASD in children in association to their

Parent’s relationship
In a sample of 100 children, parents of 60% children were having non-familial
relationship, while parents of 45% children were cousins.
4.5.1 Association of parent’s relationship of autistic children with

The association of parent’s relationship of autistic children with 15 parameters

of the Childhood Autism Rating Scale is given below:
42
32
The p values for some of the parameters of CARS test like, “imitation”, “body
use”, “object use”, “fear or nervousness”, “verbal communication”, “non-
verbal communication”, “body use, “adaptation to change”, and “activity
level”, are (0.11, 0.18, 0.09, 0.75, 0.20, 0.89, 0,93, 0.16 and 0.39) respectively,
and all these values are greater than the alpha value (0.05) hence , parent’s
relationship of the autistic children and these factors are independent of each
other , while p values for some variables of CARS test like for “relating to
people” the value is 0.02, for “emotional response” the value is 0.03, for
“visual response” the value is 0.04, for “taste , smell and touch response and
use” the value is 0.03, for “listening response” the value is 0.002, for “level
and consistency of intellectual response” the value is 0.03, and for “general
impressions” the value is 0.00, all these values showed significant results
(shown in graphs and tables) hence these factors are associated with
socioeconomic status of children with ASD.
Table 4.5: Chi square table; shows the association of parent’s relationship and
the level of relatedness of children with ASD with other people.
Chi-Square Tests
Asymptoti
c
Valu Significanc
e df e (2-sided)
Pearson Chi- 7.65 2 .022

Square 9a

2
43
32
Figure 4.5: Bar chart representing the association of parent’s relationship with
emotional response of children with ASD.
Table 4.5.1: Chi square table; shows the association of parent’s relationship
and visual response of children with ASD.
Chi-Square Tests
Asymptotic
Significance (2-
Value df sided)
44
32
Figure 4.5.1: Bar chart representing the association of parent’s relationship

with taste , smell and touch response and use in children with ASD.
and listening response of children with ASD.
Chi-Square Tests
Asymptotic
Significance (2-
Value Df sided)
45
32
Figure 4.5.2: Bar chart representing the association of parent’s relationship

with level and consistency of intellectual response of children with ASD.
and general impressions of children with ASD.
Chi-Square Tests
Asymptotic
Significance (2-
Value df sided)
46
32
4.6 Prevalence of ASD in children in association to partnership

status of their parents
In a sample of 100 autistic children, partnership status of the parents of 20%
children was single, while parents of 80% shows the partnership status of
partnered.
4.6.1 Association of partnership status of parents of autistic children with

The association of partnership status of parents of autistic children with 15

parameters of the Childhood Autism Rating Scale is given below:
The p values for all the parameters of CARS test were greater than the alpha
value (0.05) hence, partnership status of parents of autistic children and these
factors are independent of each other. None of them have significant value, so
47
32
these variables are not associated with partnership status of parents of children
with ASD.
48
46
DISCUSSION
Autism is a complex disorder with varying degrees of impairment in areas like

communication skills, social interactions, and restricted, repetitive, or
stereotyped patterns of behavior (Jepson and Johnson, 2007). Causes of ASD
include both genetic and environmental factors. Several standardized
screening tools exist to diagnose ASD at an early age, these include (STAT),
(Zwaigenbaum et al., 2018), (ADOS), (Blank et al., 2020) (DISCO), (ADI-R),
(SRS), (SCQ), (CARS) can be used to assess a child’s symptoms of ASD.
While many tools to screen and diagnose ASD exist, two of the leading autism
diagnostic tools in use today are DSM-5 and M-CHAT.
The World Health Organization (WHO) estimates the international prevalence

of ASD at 0.76%; however, this only accounts for approximately 16% of the
global child population (Baxter et al., 2015). Current prevalence is estimated
to be at least 1.5% in developed countries, with recent increases primarily
among those without comorbid intellectual disability. The prevalence of
typical autism across the world is generally reported to be 10 per 10,000
(J Autism Dev Disord, 2003). ASD occurs in all racial, ethnic, and
socioeconomic groups, but its diagnosis is far from uniform across these
groups. ASD is more common in males (Tartaglia et al., 2017).
The aim of the present study was to find out the prevalence of Autism
Spectrum Disorder in children aged 3-17 years in clinical settings. Prevalence
of ASD is increasing day by day and affecting a lot of people all over the
world. The data suggested that from the 15 parameters of the CARS test which
was applied for the study on socioeconomic status, age , gender ,partnership
status of parents, parent’s relationship and residence of the children under
study, many of the parameters of CARS test showed association with the age ,
socioeconomic status, gender, residence, and partnership status of parents and
while on the other hand none of the factors of CARS parameters (e.g.,
emotional response, body use, activity level etc) showed association with
parent’s relationship.
46
47
From the study data it is concluded that the rate of ASD is high among
children with age range of 3-17 years with varying symptoms and severity
level. The prevalence of autism in children with age range of 3-5 years is 14%,
the prevalence is 29% in children with age range of 6-8 years, similarly the
prevalence percentages for age range of (9-11 years, 12-14 years, 15-17 years)
are (25%, 17% and 15%) respectively. Many studies from different continents
showed different percentages of prevalence of autism among children of
different age ranges depending upon the children’s genetics and environment.
It was also observed that with increasing age the symptoms of autism get
worsen.
In a sample of 100 children, 72% prevalence of autism was found in children

of urban areas and 28% prevalence of autism was observed in children belong
to rural areas. Studies in Asia, Europe, and North America have identified
individuals with ASD with an average prevalence of between 1% and 2%
(CDC, 2016). The prevalence was significantly higher among children
residing in rural areas as compared to urban areas. This was in contrast to an
Arab study, where most of affected children were from urban areas, especially
in Egypt and Jordan so we concluded that the prevalence of autism may or
may not depend on residence of the children with ASD.
The data shows the percentage of male to female ratio of 50% that is due the
small sample size while the actual male/female ratio world-wide is 3:1 as it is
more prevalent in males. Loomes et al., (2017), analyzed that true male-to-
female ratio is closer to 3:1. The median male-to-female ratio was 4.2. Not
only are females less likely to present with overt symptoms, they are more
likely to mask their social deficits through a process called “camouflaging”,
further hindering a timely diagnosis (Volkmar et al., 2014).
The sample of 100 children shows, that, 19% prevalence of autism was
observed in children of upper class families, 77 % prevalence of autism was
observed in children of middle class families, and 4% prevalence of autism in
children of lower class families. The racial/ethnic disparities in ASD are
complex and reflect multiple levels of inequities which range from individual
47
48
etiologic factors, non-etiologic factors to environmental etiologic factor

(Parsons et al., 2014).
For up-coming studies on prevalence of ASD, it is suggested that the accuracy

of data is the most important part and above that study from a large population
will give results with more accuracy. ASD is a serious life challenging
disorder and awareness should be spread about it at least, in order to save and
improve lives.
48
49
CONCLUSION
The goal of the study was to find out the prevalence of ASD in children aged
3-17 years from clinical settings using CARS test, from Lahore. The sample
was collected and studied thoroughly to find out how CARS parameters are
effected by the age, socioeconomic status, gender, residence, parent’s
relationship and partnership status of parents of children with ASD. Analysis
of results suggested that many parameters of CARS test were affected by age
and gender of the child with ASD majorly while residence, socioeconomic
status, partnership status of parent’s were seemed to have affect on CARS
parameters and parent’s relationship of child with ASD did not affect any of
the parameters this study will assist in finding the association of CARS
parameters with socioeconomic status of the person under study.
49
50
REFERENCES
Agrawal, S., Rao, S. C., Bulsara, M. K., and Patole, S. K. 2018. Prevalence of
autism spectrum disorder in preterm infants: a meta-
analysis. Pediatrics, 142(3).
Akhter, S., Hussain, A. E., Shefa, J., Kundu, G. K., Rahman, F., and Biswas,
A. 2018. Prevalence of Autism Spectrum Disorder (ASD) among the children
aged 18 - 36 months in a rural community of Bangladesh: A cross-sectional
study. F1000Research, 7.
Al-Mamri, W., Idris, A. B., Dakak, S., Al-Shekaili, M., Al-Harthi, Z.,
Alnaamani, A. M., and Islam, M. M. 2019. Revisiting the prevalence of autism
spectrum disorder among Omani children: a multicentre study. Sultan Qaboos
University Medical Journal, 19(4): e305.
Autism and Developmental Disabilities Monitoring Network Surveillance

Year 2010 Principal Investigators. 2014. Prevalence of autism spectrum
disorder among children aged 8 years—autism and developmental disabilities
monitoring network, 11 sites, United States, 2010. Morbidity and Mortality
Weekly Report: Surveillance Summaries, 63(2): 1 - 21.
Bachmann, C. J., Gerste, B., and Hoffmann, F. 2018. Diagnoses of autism

spectrum disorders in Germany: time trends in administrative prevalence and
diagnostic stability. Autism, 22(3): 283 - 290.
Baxter, A. J., Brugha, T. S., Erskine, H. E., Scheurer, R. W., Vos, T., and
Scott, J. G. 2015. The epidemiology and global burden of autism spectrum
disorders. Psychological Medicine, 45(3): 60 - 613.
Bougeard, C., Picarel-Blanchot, F., Schmid, R., Campbell, R., and Buitelaar, J.
2021. Prevalence of autism spectrum disorder and co-morbidities in children
and adolescents: A systematic literature review. Frontiers in Psychiatry, 1834.
Brignell, A., Chenausky, K. V., Song, H., Zhu, J., Suo, C., and Morgan, A. T.
2018. Communication interventions for autism spectrum disorder in minimally
verbal children. The Cochrane Database of Systematic Reviews, 11(11):
CD012324.
Broder-Fingert, S., Sheldrick, C. R., and Silverstein, M. 2018. The Value of

State Differences in Autism When Compared to a National Prevalence
Estimate. Pediatrics, 142(6): e20182950.
50
51
Brugha, T., Cooper, S. A., McManus, S., Purdon, S., Smith, J., Scott, F. J., and
Tyrer, F. 2012. Estimating the prevalence of autism spectrum conditions in
adults: extending the 2007 Adult psychiatric. Semanticscholar.
Chaaya, M., Saab, D., Maalouf, F. T., and Boustany, R. M. 2016. Prevalence
of autism spectrum disorder in nurseries in Lebanon: a cross-sectional
study. Journal of Autism and Developmental Disorders, 46(2): 514-522.
Cummings, K., Watkins, A., Jones, C., Dias, R., and Welham, A. 2022.
Behavioral and psychological features of PTEN mutations: a systematic
review of the literature and meta-analysis of the prevalence of autism
spectrum disorder characteristics. Journal of Neurodevelopmental
Disorders, 14(1): 1 - 27.
Davidovitch, M., Hemo, B., Manning-Courtney, P., and Fombonne, E. 2013.

Prevalence and incidence of autism spectrum disorder in an Israeli
population. Journal of Autism and Developmental Disorders, 43(4): 785 - 793.
Dein, K., Hassiotis, A., Woodbury-Smith, M., Roychowdhury, A., Squires, R.,
and Freestone, M. 2021. Prevalence of autism within medium secure units: a
feasibility study. The Journal of Forensic Psychiatry and Psychology, 32(6):
861 - 878.
Dekkers, L., Groot, N. A., Díaz Mosquera, E. N., Andrade Zúñiga, I. P., and
Delfos, M. F. 2015. Prevalence of autism spectrum disorders in Ecuador: A
pilot study in Quito. Journal of Autism and Developmental Disorders, 45(12):
4165 - 4173.
Delobel-Ayoub, M., Saemundsen, E., Gissler, M., Ego, A., Moilanen, I.,
Ebeling, H., and Schendel, D. 2020. Prevalence of autism spectrum disorder in
7–9-year-old children in Denmark, Finland, France and Iceland: a population-
based registries approach within the ASDEU project. Journal of Autism and
Developmental Disorders, 50(3): 949 - 959.
Dietz, P. M., Rose, C. E., McArthur, D., and Maenner, M. 2020. National and
state estimates of adults with autism spectrum disorder. Journal of Autism and
Ezell, J., Hogan, A., Fairchild, A., Hills, K., Klusek, J., Abbeduto, L., and
Roberts, J. 2019. Prevalence and predictors of anxiety disorders in adolescent
and adult males with autism spectrum disorder and fragile X
syndrome. Journal of Autism and Developmental Disorders, 49(3): 1131 -
1141.
Fombonne, E. 2018. The rising prevalence of autism. Journal of Child

Psychology and Psychiatry, 59(7): 717 - 720.
51
52
Fujino, H., Saito, T., Matsumura, T., Shibata, S., Iwata, Y., Fujimura, H., and
Imura, O. 2018. Autism spectrum disorders are prevalent among patients with
dystrophinopathies. Neurological Sciences, 39(7): 1279 - 1282.
Goldman, S. E., Richdale, A. L., Clemons, T., and Malow, B. A. 2012.

Parental sleep concerns in autism spectrum disorders: variations from
childhood to adolescence. Journal of Autism and Developmental
Disorders, 42(4): 531 - 538.
Hidalgo, P. M., Moreso, N. V., and Sans, J. C. 2021. Autism spectrum

disorder prevalence and associated sociodemographic factors in the school
population: EPINED study. Autism: The International Journal of Research
and Practice, 25(7): 1999 - 2011.
Hodges, H., Fealko, C., and Soares, N. 2020. Autism spectrum disorder:
definition, epidemiology, causes, and clinical evaluation. Translational
Pediatrics, 9(Suppl 1): S55 - S65.
Imran, N., and Azeem, M. W. 2014. Autism spectrum disorders: perspective

from Pakistan. Comprehensive Guide to Autism. New York: Springer, 2483 -
2496.
Inoue, T., Otani, R., Iguchi, T., Ishii, R., Uchida, S., Okada, A., and Sakuta, R.
2021. Prevalence of autism spectrum disorder and autistic traits in children
with anorexia nervosa and avoidant/restrictive food intake disorder. Bio
Psycho Social Medicine, 15(1): 1 - 11.
Jin, Z., Yang, Y., Liu, S., Huang, H., and Jin, X. 2018. Prevalence of DSM-5
autism spectrum disorder among school-based children aged 3–12 years in
Shanghai, China. Journal of Autism and Developmental Disorders, 48(7):
2434 - 2443.
Kamal Nor, N., Ghozali, A. H., and Ismail, J. 2019. Prevalence of overweight
and obesity among children and adolescents with autism spectrum disorder
and associated risk factors. Frontiers in Pediatrics, 7: 38.
Khan, S., Qayyum, R., and Iqbal, J. 2019. Prevalence of autism spectrum
disorders (ASD) and attention deficit hyperactivity disorders (ADHD) among
adult psych. PAFMJ, 69(2): 419 - 23.
Kim, Y. S., Fombonne, E., Koh, Y. J., Kim, S. J., Cheon, K. A., and
Leventhal, B. L. 2014. A comparison of DSM-IV pervasive developmental
disorder and DSM-5 autism spectrum disorder prevalence in an epidemiologic
sample. Journal of the American Academy of Child and Adolescent
Psychiatry, 53(5): 500 - 508.
52
53
Kincaid, D. L., Doris, M., Shannon, C., and Mulholland, C. 2017. What is the
prevalence of autism spectrum disorder and ASD traits in psychosis? A
systematic review. Psychiatry Research, 250: 99 - 105.
Kumar, A., Juneja, M., and Mishra, D. 2016. Prevalence of autism spectrum
disorders in siblings of Indian children with autism spectrum
disorders. Journal of Child Neurology, 31(7): 873 - 878.
Li, Y. J., Xie, X. N., Lei, X., Li, Y. M., and Lei, X. 2020. Global prevalence of
obesity, overweight and underweight in children, adolescents and adults with
autism spectrum disorder, attention‐deficit hyperactivity disorder: A
systematic review and meta‐analysis. Obesity Reviews, 21(12): e13123.
Liu, L., Zhang, D., Rodzinka-Pasko, J. K., and Li, Y. M. 2016. Environmental
risk factors for autism spectrum disorders. Der Nervenarzt, 87(2); 55 - 61.
Liu, X., Sun, X., Sun, C., Zou, M., Chen, Y., Huang, J., and Chen, W. X.
2022. Prevalence of epilepsy in autism spectrum disorders: A systematic
review and meta-analysis. Autism, 26(1): 33 - 50.
Loomes, R., Hull, L., and Mandy, W. P. L. 2017. What is the male-to-female
ratio in autism spectrum disorder? A systematic review and meta-
analysis. Journal of the American Academy of Child and Adolescent
Psychiatry, 56(6): 466 - 474.
Lordan R., Storni C., and De Benedictis CA. 2021. Autism Spectrum
Disorders: Diagnosis and Treatment. Brisbane (AU): Exon Publications; 2021
Aug 20. Chapter 2.
Lugo-Marin, J., Magan-Maganto, M., Rivero-Santana, A., Cuellar-Pompa, L.,

Alviani, M., Jenaro-Rio, C., and Canal-Bedia, R. 2019. Prevalence of
psychiatric disorders in adults with autism spectrum disorder: A systematic
review and meta-analysis. Research in Autism Spectrum Disorders, 59, 22 -
33.
Maenner, M. J., Shaw, K. A., Bakian, A. V., Bilder, D. A., Durkin, M. S.,
Esler, A., and Cogswell, M. E. 2021. Prevalence and characteristics of autism
spectrum disorder among children aged 8 years—autism and developmental
disabilities monitoring network, 11 sites, United States, 2018. MMWR
Surveillance Summaries, 70(11): 1.
Malcolm-Smith, S., Hoogenhout, M., Ing, N., Thomas, K. G., and de Vries, P.
2013. Autism spectrum disorder Global challenges and local
opportunities. Journal of Child and Adolescent Mental Health, 25(1): 1 - 5.
Marlborough, M., Welham, A., Jones, C., Reckless, S., and Moss, J. 2021.
Autism spectrum disorder in females with fragile X syndrome: a systematic
53
54
review and meta-analysis of prevalence. Journal of Neurodevelopmental

Disorders, 13(1): 1 - 19.
May, T., Brignell, A., Hawi, Z., Brereton, A., Tonge, B., Bellgrove, M. A.,
and Rinehart, N. J. 2018. Trends in the overlap of autism spectrum disorder
and attention deficit hyperactivity disorder: prevalence, clinical management,
language and genetics. Current Developmental Disorders Reports, 5(1): 49 -
57.
Melo, C., Ruano, L., Jorge, J., Pinto Ribeiro, T., Oliveira, G., Azevedo, L.,
and Temudo, T. 2020. Prevalence and determinants of motor stereotypies in
autism spectrum disorder: A systematic review and meta-
analysis. Autism, 24(3): 569 - 590.
Monteiro, S. A., Spinks-Franklin, A., Treadwell-Deering, D., Berry, L.,

Sellers-Vinson, S., Smith, E., Voigt, R. G. 2015. Prevalence of autism
spectrum disorder in children referred for diagnostic autism
evaluation. Clinical Pediatrics, 54(14): 1322 - 1327.
Morales-Hidalgo, P., Roigé-Castellví, J., Hernandez-Martinez, C., Voltas, N.,

and Canals, J. 2018. Prevalence and characteristics of autism spectrum
disorder among Spanish school-age children. Journal of Autism and
Moss, J., Richards, C., Nelson, L., and Oliver, C. 2013. Prevalence of autism
spectrum disorder symptomatology and related behavioural characteristics in
individuals with Down syndrome. Autism, 17(4): 390 - 404.
Narzisi, A., Posada, M., Barbieri, F., Chericoni, N., Ciuffolini, D., Pinzino,
M., and Muratori, F. 2020. Prevalence of Autism Spectrum Disorder in a large
Italian catchment area: A school-based population study within the ASDEU
project. Epidemiology and Psychiatric Sciences, 29.
Noor, N., Talha, M., Ahmad, S. A., Mohydin, M., Shah, S. S. A., Mohydin, S.,
and Faheem, F. 2021. Evaluation of the Prevalence of Childhood Autism
Awareness amongst Medical Professionals in Pakistan. Consultant, 1: 1 - 0.
Ouellette-Kuntz, H., Coo, H., Lam, M., Breitenbach, M. M., Hennessey, P. E.,
Jackman, P. D., and Chung, A. M. 2014. The changing prevalence of autism in
three regions of Canada. Journal of Autism and Developmental
Disorders, 44(1): 120 - 136.
Ouhtit, A., Al-Farsi, Y., Al-Sharbati, M., Waly, M., Gupta, I., Al-Farsi, O.,
and Al-Adawi, S. 2015. Underlying factors behind the low prevalence of
autism spectrum disorders in Oman: Sociocultural perspective. Sultan Qaboos
University Medical Journal, 15(2): e213.
54
55
Özerk, K. 2018. Prevalence of autism/ASD in the capital city of Oslo,

Norway. International Electronic Journal of Elementary Education, 11(1): 23
- 30.
Park, I., Gong, J., Lyons, G. L., Hirota, T., Takahashi, M., Kim, B., and
Leventhal, B. L. 2020. Prevalence of and factors associated with school
bullying in students with autism spectrum disorder: A cross-cultural meta-
analysis. Yonsei Medical Mournal, 61(11): 909.
Pelly, L., Vardy, C., Fernandez, B., Newhook, L. A., and Chafe, R. 2015.
Incidence and cohort prevalence for autism spectrum disorders in the Avalon
Peninsula, Newfoundland and Labrador. Canadian Medical Association Open
Access Journal, 3(3): E276 - E280.
Raina, S. K., Chander, V., Bhardwaj, A. K., Kumar, D., Sharma, S., Kashyap,
V., and Bhardwaj, A. 2017. Prevalence of autism spectrum disorder among
rural, urban, and tribal children (1–10 years of age). Journal of Neurosciences
in Rural Practice, 8(03): 368 - 374.
Randall, M., Sciberras, E., Brignell, A., Ihsen, E., Efron, D., Dissanayake, C.,
and Williams, K. 2016. Autism spectrum disorder: Presentation and
prevalence in a nationally representative Australian sample. Australian and
New Zealand Journal of Psychiatry, 50(3): 243 - 253.
Ravizza, S. M., Solomon, M., Ivry, R. B., and Carter, C. S. 2013. Restricted
and repetitive behaviors in autism spectrum disorders: the relationship of
attention and motor deficits. Development and Psychopathology, 25(3): 773 -
784.
Richards, C., Jones, C., Groves, L., Moss, J., and Oliver, C. 2015. Prevalence
of autism spectrum disorder phenomenology in genetic disorders: a systematic
review and meta-analysis. The Lancet Psychiatry, 2(10): 909 - 916.
Richards, C., Jones, C., Groves, L., Moss, J., and Oliver, C. 2015. Prevalence
of autism spectrum disorder phenomenology in genetic disorders: a systematic
review and meta-analysis. The Lancet Psychiatry, 2(10): 909 - 916.
Rudra, A., Belmonte, M. K., Soni, P. K., Banerjee, S., Mukerji, S., and
Chakrabarti, B. 2017. Prevalence of autism spectrum disorder and autistic
symptoms in a school‐based cohort of children in Kolkata, India. Autism
Research, 10(10): 1597 - 1605.
Saito, M., Hirota, T., Sakamoto, Y., Adachi, M., Takahashi, M., Osato-
Kaneda, A., and Nakamura, K. 2020. Prevalence and cumulative incidence of
autism spectrum disorders and the patterns of co-occurring
neurodevelopmental disorders in a total population sample of 5-year-old
children. Molecular Autism, 11(1): 1 - 9.
55
56
Schnabel, A., Youssef, G. J., Hallford, D. J., Hartley, E. J., McGillivray, J. A.,
Stewart, M., and Austin, D. W. 2020. Psychopathology in parents of children
with autism spectrum disorder: A systematic review and meta-analysis of
prevalence. Autism, 24(1): 26 - 40.
Seiverling, L., Towle, P., Hendy, H. M., and Pantelides, J. 2018. Prevalence of
feeding problems in young children with and without autism spectrum
disorder: a chart review study. Journal of Early Intervention, 40(4): 335 -
346.
Skonieczna‐Żydecka, K., Gorzkowska, I., Pierzak‐Sominka, J., and Adler, G.

2017. The prevalence of autism spectrum disorders in West Pomeranian and
Pomeranian regions of Poland. Journal of Applied Research in Intellectual
Disabilities, 30(2): 283 - 289.
Thomaidis, L., Mavroeidi, N., Richardson, C., Choleva, A., Damianos, G.,
Bolias, K., and Tsolia, M. 2020. Autism spectrum disorders in Greece:
nationwide prevalence in 10–11-year-old children and regional
disparities. Journal of Clinical Medicine, 9(7): 2163.
Tiley, C., and Kyriakopoulos, M. 2021. The prevalence of autism spectrum

traits and autism spectrum disorders in children and adolescents with
obsessive compulsive disorder: a systematic review. BJPsych Open, 7(S1):
S56 - S56.
Tonnsen, B. L., Boan, A. D., Bradley, C. C., Charles, J., Cohen, A., and
Carpenter, L. A. 2016. Prevalence of autism spectrum disorders among
children with intellectual disability. American Journal on Intellectual and
Developmental Disabilities, 121(6): 487 - 500.
Toseeb, U., McChesney, G., and Wolke, D. 2018. The prevalence and
psychopathological correlates of sibling bullying in children with and without
autism spectrum disorder. Journal of Autism and Developmental
Disorders, 48(7): 2308 - 2318.
van Bakel, M. M. E., Delobel-Ayoub, M., Cans, C., Assouline, B., Jouk, P. S.,
Raynaud, J. P., and Arnaud, C. 2015. Low but increasing prevalence of autism
spectrum disorders in a French area from register-based data. Journal of
Autism and Developmental Disorders, 45(10): 3255 - 3261.
Vivanti, G., Tao, S., Lyall, K., Robins, D. L., and Shea, L. L. 2021. The
prevalence and incidence of early‐onset dementia among adults with autism
spectrum disorder. Autism Research, 14(10): 2189 - 2199.
Whitney, D. G., and Shapiro, D. N. 2019. National prevalence of pain among

children and adolescents with autism spectrum disorders. JAMA
pediatrics, 173(12): 1203 - 1205.
56
57
Williams, Z. J., Suzman, E., and Woynaroski, T. G. 2021. Prevalence of

decreased sound tolerance (hyperacusis) in individuals with autism spectrum
disorder: A meta-analysis. Ear and Hearing, 42(5): 1137 - 1150.
Worley, J. A., Matson, J. L., Sipes, M., and Kozlowski, A. M. 2011.

Prevalence of autism spectrum disorders in toddlers receiving early
intervention services. Research in Autism Spectrum Disorders, 5(2): 920 - 925
Xie, S., Heuvelman, H., Magnusson, C., Rai, D., Lyall, K., Newschaffer, C. J.,
and Abel, K. 2017. Prevalence of autism spectrum disorders with and without
intellectual disability by gestational age at birth in the Stockholm youth
cohort: a register linkage study. Paediatric and Perinatal
Epidemiology, 31(6): 586 - 594.
Yuan, J., Li, M., and Lu, Z. K. 2021. Racial/ethnic disparities in the
prevalence and trends of autism spectrum disorder in US children and
adolescents. JAMA Network Open, 4(3): e210771 - e210771.
Zeidan, J., Fombonne, E., Scorah, J., Ibrahim, A., Durkin, M. S., Saxena, S.,
and Elsabbagh, M. 2022. Global prevalence of autism: a systematic review
update. Autism Research, 15(5): 778 - 790.
Zhou, H., Xu, X., Yan, W., Zou, X., Wu, L., Luo, X., and Wang, Y. 2020.
Prevalence of autism spectrum disorder in China: a nationwide multi-center
population-based study among children aged 6 to 12 years. Neuroscience
Bulletin, 36(9): 961 - 971.
57
vi
vi

Final Thesis in Process

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Final Thesis in Process

Uploaded by

Copyright:

Available Formats

INTRODUCTION

Autism Spectrum Disorder is now defined by two categories: (a) impaired

Restricted and repetitive behaviors (RRBs) are hallmark symptoms of autism

Brain overgrowth both in terms of cortical size and additionally in terms of

Maternal history of autoimmune disease, such as diabetes, thyroid disease, or

Several standardized screening tools exist to diagnose ASD at an early age,

Whether and to what extent ASD can or should be treated is a controversial

The World Health Organization (WHO) estimates the international prevalence

global child population (Baxter et al., 2015). Current prevalence is estimated

ASD is more common in males (Tartaglia et al., 2017) but in a recent meta-

Current prevalence was estimated to be at least 1.5% in developed countries

A CDC–sponsored surveillance project to determine and monitor the

approximately 20% of children meeting the ADDM case definition of ASD

Changes in autism diagnostic criteria found in DSM-5 may affect autism

United States provided estimates of the prevalence of ASD and other

Study investigators in China independently conducted a systematic literature

Using the Longitudinal Study of Australian Children (LSAC) data, prevalence

The prevalence of ASD in Germany was estimated to be about 0.25% in 0- to

In 2002/2003, the National Epidemiologic Database for the Study of Autism in

To determine the prevalence of autism spectrum disorder (ASD) in preschool

To estimate of the prevalence of autism spectrum disorder (ASD) among

A study was conducted to estimate the prevalence of ASD in a large

and 11.5%, respectively (Al-Mandhari et al., 2009). It appears that there was a

In Israel, three epidemiological studies on ASD have been published. An

India is the largest exception to the list of countries with an estimate of

population (Elsabbagh et al., 2012). The study included children aged 3–8

Studies on autism spectrum disorders (ASDs) have largely focused on

This study determined the prevalence of autism spectrum disorders in 201

were 5 males and 5 females, giving a prevalence of 4.9% in female siblings

In Bangladesh, a study has explored at the prevalence of ASD among rural

A study was conducted to determine the prevalence of true ASD diagnoses in

followed. Investigation of ASD prevalence was done within a general

Posphatase and tensin homologue (PTEN) is a cancer suppressor gene

between non-Hispanic White (White) and non-Hispanic Black (Black)

To estimate the prevalence of ASD in a representative school sample of the

The estimated prevalence of ASD in a population-based sample comprising

The prevalence of autism/ASD among the preschool-age children (1-5 years

ASD prevalence was estimated in 7–9 year-old children in 2015 using data

Finland, information was gathered on all children with an ASD diagnoses

Register-based prevalence rates of childhood autism (CA) and other autism

A cross-sectional study examines the prevalence of Autism spectrum disorder

Parents of children with autism spectrum disorder appear to experience high

Individuals with ASD often present co-morbid psychiatric disorders. Hossain

The literature from 2020 on the prevalence of epilepsy in autistic individuals

The rates of co-existing neurodevelopmental disorders (NDD) in a total

Individuals with autism spectrum disorder (ASD) or attention-deficit

Prevalence of obesity in Autism Spectrum Disorder (ASD) has been reported

The prevalence and incidence of early-onset dementia in individuals with ASD

Prevalence of feeding problems detected by speech therapists and

A prominent set of behavioral/psychological features associated with FXS are

Anxiety disorders affect ~15–20% of youths without neurodevelopmental

et al., 2011). Participants were males with non-syndromic ASD (n=20) or

Stereotypies were frequently reported in people with autism spectrum disorder

A number of studies have indicated that students with disabilities are at

ASD has a number of psychopathological correlates, which further reduce the

Researches have indicated that autism was over-represented among inpatients

Pain is a leading contributor to the global morbidity and disability burden.

A century ago, Bleuler considered “autism” to be one of the four core

Autism spectrum disorder (ASD) phenomenology was reported to be more

population. Syndromes reported as most likely to be associated with ASD was

Autism Spectrum Disorder (ASD) and Obsessive Compulsive Disorder (OCD)

Autism spectrum disorders (ASD) often co-occur with intellectual disability

MATERIALS AND METHODS