The global prevalence of autism spectrum disorder: a comprehensive systematic review and meta-analysis

The Future of Disentangling the Heterogeneity of Autism With Neuroimaging Studies

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition. Over the past decade, a considerable number of approaches have been developed to identify potential neuroimaging-based biomarkers of ASD that have uncovered specific neural mechanisms that underlie behaviors associated with ASD. However, the substantial heterogeneity among individuals who are diagnosed with ASD hinders the development of biomarkers. Disentangling the heterogeneity of ASD is pivotal to improving the quality of life for individuals with ASD by facilitating early diagnosis and individualized interventions for those who need support. In this review, we discuss recent advances in neuroimaging that have facilitated the characterization of the heterogeneity of this condition using 3 frameworks: neurosubtyping, dimensional models, and normative models. We also discuss the challenges, possible solutions, and clinical utility of these 3 frameworks. We argue that several factors need to be considered when parsing heterogeneity using neuroimaging, including co-occurring conditions, neurodevelopment, heredity and environment, and multisite and multimodal data. We close with a discussion of future directions for achieving a better understanding of the neural mechanisms that underlie neurodevelopmental heterogeneity and the future of precision medicine in ASD.

Novel Procedures for Evaluating Autism Online in a Culturally Diverse Population of Children: Protocol for a Mixed Methods Pathway Development Study

BACKGROUND

Current autism assessment procedures are costly and resource-intensive. The COVID-19 pandemic accelerated the adoption of telemedicine, highlighting the benefits of innovative diagnostic tools. Telemedicine-based pathways could enhance accessibility and equity in autism diagnostics.

OBJECTIVE

The Children with Autism Technology Enabled Assessment (CHATA) project aims to develop and pilot an open-source autism diagnostic pathway for children up to 5 years old, delivered through telemedicine. The pathway is designed to be culturally and linguistically adaptable, increasing its applicability to diverse populations and integrating with existing National Health Service digital systems.

METHODS

Initial pathway development was informed by systematic evidence reviews, coproduction, and mixed methods usability. CHATA comprises 2 key elements: online self-completed standardized autism questionnaires and a structured online interview and observation by a trained clinician. Out of 60 families near the top of the local waiting list will be invited to participate in the pilot evaluation, assessed using both the CHATA and usual assessment pathways. Sensitivity and specificity will be calculated by comparing the diagnosis of autism through CHATA with usual care. Quantitative usability assessment will be gathered from all families using the System Usability Scale (where a mean above 68 indicates above-average usability). A subset of CHATA assessments will be reviewed for interrater reliability (measured by the Cohen κ for categorical data [diagnosis present or absent], with values indicating the level of agreement; eg, <0 indicating no agreement, 0.61-0.80 indicating substantial agreement). Qualitative data on acceptability, feasibility, and usability will be gathered from semistructured interviews with a subset of families and health care providers. We will recruit 60 families for the main pilot study (including the usability testing) and 10-15 participants for the qualitative substudy. Data will estimate CHATA's diagnostic accuracy, validity, reliability, usability, and acceptability. Patient and public involvement will be integral throughout. The study will take place in a socio-economically deprived, ethnically diverse inner-London Borough within a community-based child health National health service responsible for the Autism assessment of children and young people up to the age of 13 years.

RESULTS

Ethics approval was received in June 2023 (Research Ethics Committee reference 22/LO/0751; IRAS project ID 320499). Data collection commenced in April 2023 and completed in October 2024. Project end date is March 2025. As of November 2024, we had enrolled 57 participants to the pilot study and 12 to the qualitative substudy.

CONCLUSIONS

The CHATA project aims to establish a novel, culturally sensitive, equitable, and accurate online autism assessment pathway. By addressing geographical and linguistic barriers, this pathway seeks to reduce service costs, shorten waiting times, and promote equity in autism diagnosis. The procedures developed are expected to be generalized to other populations nationwide.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55741.

Efficacy and Safety of Propofol as a Sole Sedative for fMRI Sedation in Autism Spectrum Disorder Individuals with Low IQ

Autism spectrum disorder (ASD) is a group of complicated neurodevelopmental disorders. Functional magnetic resonance imaging (fMRI) can help to analyze the aberrant neurological functioning in ASD. However, due to their limited cognitive abilities, ASD individuals with low IQ may face challenges in cooperating during fMRI scanning. Consequently, sedation becomes necessary for them. To analyze and evaluate the sedative efficacy and safety of a single intravenous propofol sedation regimen for ASD individuals with low IQ undergoing fMRI examination. Seventy-seven ASD individuals with low IQ, aged 4 to 23 years, who underwent fMRI examination under propofol sedation, were included. Details of the sedation protocol, evaluation indices for effectiveness such as framewise displacement (FD) and temporal signal-to-noise ratio (tSNR), as well as safety assessment measures including pulse oxygen saturation (SPO2) and blood pressure were collected. Adverse events were also recorded. Data analysis was conducted upon completion of the study. Body movement was observed in 12 patients. The median and quartiles (25th percentile, 75th percentile) of FD was 0.065 (0.057, 0.086) mm, while the tSNR averaged at 89.6 ± 11.4. The image data from sixty-two cases (80.5%) were classified as high quality based on their tSNR surpassing 80. No serious adverse events, such as oxygen desaturation, hypotension, nausea, or vomiting, occurred that necessitated hospitalization. The exclusive propofol intravenous sedation protocol employed in this study demonstrates efficacy and safety for administering fMRI examinations to ASD individuals with low IQ, thereby warranting further investigation and validation towards its adoption in clinical practice.

The Childhood Autism Rating Scale Second Edition (CARS2) and Its Applicability in an Iranian Sample

The present study aimed to evaluate the reliability and validity of the Childhood Autism Rating Scale: Second Edition (CARS2) in diagnosing individuals with autism in Iran. A mixed-method approach was used and 313 participants were recruited, with an age range of 2-32 years, for CARS2-Standard Form (ST) and 218 individuals aged 6-25 years for CARS2-High Functioning (HF). The participants were recruited from daycare centers, schools, and clinics with different developmental trajectories: autism, intellectual disabilities, and neurotypical development. All participants with autism and intellectual disabilities had been clinically diagnosed previously. In addition, the CARS2-Questionnaire of Parent Concerns (QPC) was used to gather qualitative data on 30 randomly selected parents and the perspectives of the 20 test administrators were also collected. The CARS2 had high internal consistency, inter-rater reliability, and test-retest reliability. Factor analyses revealed a one-factor structure for CARS2-ST and a three-factor structure for CARS2-HF. When adjustments were made to the cut-off points, the discriminant analyses indicated that CARS2 effectively differentiated between those with autism and typical development but less so with persons who had intellectual disabilities. The qualitative data analysis and the extracted themes suggest that the CARS2-QPC is a valid tool for collecting autism-related information from parents. Our findings suggest that the CARS2 is broadly a reliable and valid instrument for diagnosing autism spectrum in Iran in the absence of more extensive assessments.

[Pain assessment for children and adolescents with autism spectrum disorders (ASD): A systematic review]

OBJECTIVE

Pain in children and adolescents with autism spectrum disorders remains underdiagnosed due to their inherent communication difficulties. The goal of this review is to identify the most suitable methods for assessing pain in this population and for evaluating the specific perceptions of, or behavioural reactions to, pain whilst considering disorder severity and specifiers (with or without accompanying intellectual impairment, with or without accompanying language impairment).

METHOD

A systematic review and analysis of the international literature was conducted.

RESULTS

Fourteen studies were selected. No difference was found in pain-related behaviours based on the age or gender of children or adolescents with autism. Three studies showed pain-related behaviours in autism spectrum disorders to be similar to control groups. Other studies showed specific behavioural responses in autism spectrum disorders with a longer physiological and behavioural recovery time associated with an episode of acute pain in this population. Similarly, the three studies that focused on sensory perceptions of pain all showed differences in the autism spectrum disorders population compared to control groups. In hospital or daily life contexts, studies essentially showed idiosyncratic expressions, hypervigilance, motor agitation, negative emotional reactions, or vocalizations. Regarding the association of autism severity with hyposensitivity to pain, the results remain unclear even when language disorders or intellectual disabilities are also present (in conjunction with autism). The Non-Communicative Children Pain Checklist and its translation into French and Italian showed good internal validity and was used by almost half of the studies in hetero-assessment, mostly by parents. Studies recommend the inclusion of parents in the assessment in order to optimise the evaluation process. Similarly, analysis of parent/child/caregiver interviews from the studies highlights the importance of personalizing pain assessment of children and adolescents, taking into account subject-specific characteristics, pathology, and context.

CONCLUSION

An integrative and personalized approach to pain assessment appears to be the most appropriate for enhancing the understanding and detection of pain in individuals with autism spectrum disorders. This approach aligns well with a care setting where a nominated professional with a good expertise in autism is responsible for pain assessment. Given the complexity of identifying pain in individuals with autism, further qualitative studies, in conjunction with new pain exploration technologies, are considered necessary as well as a more extensive categorization of the population studies.

Taste processing in autism spectrum disorder: A translational scoping review

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent challenges in social communication and restricted/repetitive behaviors, including sensory atypicalities. Taste processing is critical for assessing the sensory and hedonic properties of food; however, it remains understudied in ASD, which may limit our understanding of the disorder's links to selective eating and nutritional deficits. This scoping review on autistic gustatory functioning followed a predefined protocol. We conducted searches across four databases and identified 37 studies involving human participants, categorized into three methodologies: questionnaires, neuroimaging, and psychophysical tests. Additionally, eight studies on ASD animal models were included to offer cross-species insights. Questionnaire data generally indicate that individuals with ASD exhibit differences in taste reactivity compared to those without ASD. Neuroimaging studies suggest potential involvement of specific brain regions, including hippocampal volume and anterior superior temporal sulcus (aSTS) connectivity in atypical taste processing. Psychophysical assessments and animal studies further reveal variability in basic taste preferences, with individuals with ASD showing particular aversion to bitterness and showing either no difference or a decreased preference for sweetness compared to typically developing peers. This review also highlights research gaps regarding specific qualitative tastes such as saltiness, sourness, and umami in ASD, limiting a comprehensive understanding of ASD's chemosensory profile and emphasizing the need for further research in these areas.

The challenge of a late diagnosis of Autism Spectrum Disorder: co-occurring trajectories and camouflage tendencies. a case report of a young Autistic female with Avoidant Restrictive Food Intake Disorder

Introduction

Autistic individuals may show several psychiatric co-occurrences, including Feeding and Eating Disorders (FEDs). Avoidant and Restrictive Food Intake Disorder (ARFID) consists of avoidance or restriction in food intake, leading to significant weight loss, nutritional deficiencies, and marked interference with psychosocial functioning. Both Autism Spectrum Disorder (ASD) and ARFID are characterized by the two main features of cognitive rigidity and sensory sensitivity, which may complicate differential diagnosis. There is a notable lack of information on the manifestation of ASD-ARFID co-occurrence, as well as tailored assessment tools and practice, and therapeutic approaches.

Case description

This report provides a detailed description of L., a young girl with a late diagnosis of ASD who also developed unspecific depressive mood disorder and ARFID in co-occurrence. After the diagnosis of ASD, L. underwent multiple evaluations to address emerging psychiatric co-occurrences and symptom exacerbation, and in order to develop the most effective integrated treatment.

Conclusion

The case of L. expands the knowledge on the phenotype of Autistic females and exemplifies how delayed diagnosis may exacerbate functioning differences and increase the camouflage phenomenon. Additionally, it underscores the importance of improving tailored evaluation, combined treatment plans, with both cognitive-behavioral therapy and drugs, and monitoring the evolving patterns of Autistic manifestations and associated psychiatric co-occurrences.

Telomere Length and Oxidative Damage in Children and Adolescents with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Autism spectrum disorder (ASD) has been reported to confer an increased risk of natural premature death. Telomere erosion caused by oxidative stress is a common consequence in age-related diseases. However, whether telomere length (TL) and oxidative indicators are significantly changed in ASD patients compared with controls remains controversial. The aim of this study was to determine the associations of ASD with TL and oxidative indicators by performing a meta-analysis of all published evidence.

METHODS

The PubMed and Embase databases were searched for articles published up to April, 2024. The effect size was expressed as standardized mean difference (SMD) and 95% confidence interval (CI) via Stata 15.0 software.

RESULTS

Thirty-nine studies were included. Pooled results showed that compared with controls, children and adolescents with ASD were associated with significantly shorter TL (SMD = -0.48; 95% CI = -0.66- -0.29; p < 0.001; particularly in males), lower total antioxidant capacity (TAC: SMD = -1.15; 95% CI = -2.01- -0.30; p = 0.008), and higher oxidative DNA (8-hydroxy-2'-deoxyguanosine, 8-OHdG: SMD = 0.63; 95% CI = 0.03-1.23; p = 0.039), lipid (hexanolyl-lysine, HEL: SMD = 0.37; 95% CI = 0.13-0.62; p = 0.003), and protein (3-nitrotyrosine, 3-NT: SMD = 0.86; 95% CI = 0.21-1.51; p = 0.01; dityrosine, DT: SMD = 0.66; 95% CI = 0.521-0.80; p < 0.01) damage. There were no significant differences between ASD and controls in 8-isoprostane and oxidative stress index after publication bias correction, and in N-formylkynurenine during overall meta-analysis.

CONCLUSIONS

TL, 8-OHdG, TAC, HEL, 3-NT, and DT represent potential biomarkers for prediction of ASD in children and adolescents.

The association between preterm delivery and autism spectrum disorder in childhood: A retrospective cohort study

BACKGROUND

Prematurity complications are a leading cause of mortality and morbidity in offspring, including adverse neurodevelopmental outcomes. The association between preterm birth (PTB) and autism spectrum disorder (ASD) remains debated.

OBJECTIVE

To investigate the association between PTB and ASD diagnosis during childhood.

METHODS

This cohort study analyzed data from community clinics and a tertiary hospital, encompassing deliveries from 2005 to 2017. ASD incidence was compared across gestational age categories: extremely preterm (<28 weeks), very preterm (28-32 weeks), moderate to late preterm (32-37 weeks), and term (≥37 weeks). Additional comparisons were made between all preterm (<37 weeks) and term deliveries (≥37 weeks). Cumulative ASD incidence was assessed using Kaplan-Meier survival curves and a Cox proportional hazards model adjusted for potential confounders.

RESULTS

Among 114 975 pregnancies, 0.3% delivered at <28 weeks, 0.6% at 28-32 weeks, and 6% at 32-37 weeks, with 6.9% preterm deliveries overall. Univariable analysis revealed a significant association between PTB and ASD (1.6% for <28 weeks vs 0.3% for 28-32 weeks vs 0.8% for 32-37 weeks vs 0.7% for term, P = 0.036). Crude ASD incidence was 0.8% (odds ratio [OR] 1.21, 95% confidence interval [CI] 0.93-1.56, P = 0.15). However, adjusted results showed no significant association: adjusted hazard ratio = 0.74 (95% CI 0.24-2.34, P = 0.61) for <28 weeks, 0.99 (95% CI 0.24-3.99, P = 0.98) for 28-32 weeks, and 1.07 (95% CI 0.81-1.43, P = 0.63) for 32-37 weeks. Kaplan-Meier analysis showed similar cumulative ASD incidence across groups (P = 0.855).

CONCLUSION

This retrospective cohort study found no significant association between PTB and childhood ASD diagnosis.

Mapping neuro-disabilities and their dimensions among under 5 years of age children in the southern agricultural corridor of Tanzania: a preliminary baseline survey

Background

Neuro-disabilities involve impairments of the nervous system, affecting brain development and functioning. Due to limited scientific data on neuro-disabilities in Tanzania, this study examines maternal characteristics in high-risk areas, such as the Southern Agricultural Growth Corridor (SAGCOT).

Methods

This cross-sectional study sampled 286 children aged 0-5 years and their mothers in the SAGCOT region. Each mother selected the youngest child within the specified age range. Multi-stage sampling was used to choose clusters and areas for the study. The Malawi Developmental Assessment Tool (M-DAT) was used to assess the children's developmental levels. Descriptive analysis determined distribution patterns, while multivariate analyses were performed to identify significant factors. Modified Poisson regression with robust standard errors estimated prevalence ratios (PRs) and their 95% confidence intervals (CIs).

Results

The study included 286 mother-child pairs from four clusters: Ihemi, Kilombero, Ludewa, and Mbarali. The children's median age was 24 months, with the majority aged between 13 and 48 months. Boys constituted a slight majority (59.4%). The majority of mothers were married (72.4%), had primary education (56.6%), and were engaged in non-farming occupations (56.3%). Neurodevelopmental assessments revealed that 11.2% of children were fully developed, while 88.8% exhibited development delays. Adjusted prevalence ratios (aPR) with 95% confidence intervals identified significant associations between developmental domains and demographic variables such as age, gender, marital status, and maternal occupation.

Conclusion

The study highlights a high prevalence of neuro-disability among children in Tanzania's southern corridor, revealing disparities across regions and the impact of factors such as gender and marital status. Targeted interventions are essential to address these developmental challenges effectively and promote optimal child development and wellbeing.

Exploring the potential of the ketogenic diet in autism spectrum disorder: metabolic, genetic, and therapeutic insights

Current treatment approaches for Autism spectrum disorder (ASD) primarily focus on symptom management rather than addressing underlying dysfunctions. The ketogenic diet (KD), a high-fat, low-carbohydrate diet inducing nutritional ketosis, has shown promise in treating epilepsy and may offer therapeutic benefits for ASD by modulating metabolic and neuroprotective pathways. This review examined the potential impact of KD on underlying mechanisms in ASD. While evidence from human studies on underlying mechanisms is limited, animal research has shown a large overlap of mechanisms modulated by KD and dysfunctions in ASD. As such, targeting multiple disrupted pathways at once, KD presents a potential multifaceted treatment approach for ASD. However, more evidence from human studies is needed on the effectiveness of KD in the modulation of underlying dysfunctions in ASD. Additionally, precision medicine approaches could help identify individuals who would benefit most from the intervention, potentially extending its use to other psychiatric conditions with similar metabolic patterns. Consequently, KD interventions might show the potential to induce a drastic paradigm shift in understanding and treating ASD.

Pharmacological treatment in autism: a proposal for guidelines on common co-occurring psychiatric symptoms

BACKGROUND

The prevalence of autism spectrum disorder (ASD) has surged, with an estimated 1 in 36 eight-year-olds in the United States meeting criteria for ASD in 2020. Autistic individuals face elevated rates of co-occurring medical, psychiatric, and behavioral conditions compared to non-autistic individuals. The rising ASD-patient demand is increasingly outpacing the capacity of ASD-specialty clinics, resulting in urgent need for autism-competent providers in general practice settings. This work aims to empower healthcare providers, especially primary care providers (PCPs), with guidelines for the recognition and safe pharmacologic management of common co-occurring psychiatric and behavioral conditions in ASD.

METHODS

Lurie Center for Autism medical providers, who have extensive experience in ASD care, delineated approaches for recognition and pharmacological treatment of sleep disturbances, attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and irritability tailored to ASD patients. Pharmacological guidelines were iteratively refined until consensus was reached. Treatment differences relative to standard of care (SOC) of non-autistic individuals are noted. Key literature and clinical trial results were reviewed to supplement clinical experience.

RESULTS

The pharmacological treatment pathways reflect how appropriate medication options for ASD patients can depend on many factors unique to the patient and can differ from established non-autistic SOC. Key takeaways include: For sleep disturbances in ASD, initial strategies align with non-autistic SOC, emphasizing sleep hygiene and melatonin use. First-line recommendations for treating ADHD, anxiety, and depression in ASD differ from non-autistic SOC; α2-adrenergic agonists are more suitable than stimulants for some ASD-ADHD patients, buspirone and mirtazapine are preferred to selective serotonin reuptake inhibitors (SSRIs) for anxiety, and duloxetine, mirtazapine, bupropion, and vortioxetine are recommended ahead of SSRIs for depression. Addressing irritability in ASD requires interdisciplinary evaluation of contributing factors, and guanfacine, risperidone, or aripiprazole may be appropriate, depending on severity.

CONCLUSIONS

Recognition and treatment of co-occurring psychiatric and behavioral conditions in autistic patients must account for differences in clinical presentation and medication effectiveness and tolerability. Drawing on evidence-based clinical insights, these guidelines seek to support PCPs in making informed decisions when prescribing medications for ASD patients with co-occurring psychiatric and behavioral conditions, ultimately enhancing access to timely, comprehensive care for all individuals with ASD.

The Co-Occurrence of Autism and Avoidant/Restrictive Food Intake Disorder (ARFID): A Prevalence-Based Meta-Analysis

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder characterized by extensive avoidance and/or restriction of food. Existing research demonstrates that ARFID is over-represented in Autistic populations and vice-versa, with both groups exhibiting shared characteristics. This meta-analysis investigated the co-occurrence between ARFID and autism via determination of autism prevalence in ARFID populations, and ARFID prevalence in Autistic groups.

METHOD

This review systematically identified literature evaluating those with ARFID and Autistic individuals. Literature was searched for using SCOPUS, MEDLINE, and Web of Science. Selected publications included Autistic individuals and those with ARFID who either received a formal diagnosis of autism and/or ARFID or met clinical threshold cut-off scores on validated autism and/or ARFID questionnaires. Prevalence was reported in proportion-based values alongside 95% confidence intervals (CIs).

RESULTS

This meta-analysis identified 21 studies (kARFID = 18 papers; kAutism = 3 papers) comprising of n = 7442 participants (nARFID = 1708; nAutism = 5734). Prevalence of autism diagnoses was 16.27% in those with ARFID (95% CI = 8.64%-28.53%), and ARFID prevalence in Autistic groups was 11.41% (95% CI = 2.89%-35.76%). Gender and ethnicity served as significant sources of heterogeneity in ARFID papers. There was insufficient data to provide comparator values or prevalence across study population and distinct underpinning drivers of ARFID.

DISCUSSION

Meta-analytic findings highlight significant rates of co-occurrence between autism and ARFID, suggesting that in clinical settings, it may be beneficial to consider screening Autistic individuals for ARFID and vice-versa. Future research should further investigate co-occurrence across ARFID profiles, gender, and ethnicity.

Oxytocin in autism: Rethinking treatment and research through a neurodivergent perspective

This perspective piece addresses critical challenges in oxytocin-based interventions for autism, drawing on neurodivergent perspectives to highlight key issues in research relevance and inclusivity. Although oxytocin has been posited to modulate social and routinized behaviors in autistic individuals, empirical findings on its efficacy remain inconsistent. We argue that these behavioral targets may reflect neurotypical biases, often disregarding autistic individuals' perspectives, thereby limiting intervention acceptability and efficacy. Past research has frequently excluded marginalized autistic populations, including individuals with intellectual disabilities or gender-diverse identities, exacerbating generalizability issues. This piece advocates for a reorientation of research objectives in autism, proposing a shift from modifying core autistic behaviors towards enhancing quality of life through participatory research. By integrating autistic perspectives into study design and outcome selection, researchers move away from deficit-oriented frameworks and instead prioritize socially valid outcomes, such as reducing anxiety and improving adaptive functioning. Further, the perspective piece critiques the reliance on animal models, which often lack translational validity due to autism's complex social and communicative dimensions. In closing, we underscore the importance of inclusive, reproducible autism research practices that align with the lived experiences and priorities of autistic individuals. Embracing participatory research, alongside rigorous methodological adjustments, can foster advancements that effectively support the well-being of the autistic community.

Global prevalence of depression in caregivers of children with autism: A systematic review and meta-analysis

PROBLEM

Depression is reported as the most common disorder among caregivers, especially for caregivers of children with autism. However, limited systematic reviews have investigated the prevalence of depressive symptoms among these caregivers. This systematic review and meta-analysis aim to synthesize the prevalence of global depressive symptoms among caregivers of children with autism and identify associated factors.

ELIGIBILITY CRITERIA

Articles were limited to English language and reported on the prevalence of depressive symptoms among formal or informal caregivers, aged 18 or older, of children with ASD, with no publication year restrictions.

SAMPLE

A total of 40 included studies involving 13,853 caregivers of children with autism were included.

RESULTS

Meta-analysis of 40 included studies involving 13,853 caregivers of children with autism showed a pooled prevalence estimate of 45 % (95 % CI: 39.0-51.0). Depressive symptoms were most prevalent in European studies, with a rate of 54 % (N: 980), closely followed by the Eastern Mediterranean region at 53 % (N:1071). The South-East Asia and Western Pacific region exhibited a prevalence of 40 % (N: 5719), while the Americas reported a rate of 38 % (N: 6083).

CONCLUSION

This review presents compelling evidence of a high global prevalence rate of 45 % for depressive symptoms among caregivers of children with ASD.

IMPLICATIONS

To enhance nursing support for caregivers of children with ASD, specific interventions are needed. Nurses should integrate mental health screenings into regular check-ups, link caregivers to community resources, and receive specialized training. Promoting respite care and collaborating with stakeholders can further address caregiver stress and mental health stigma.

Parental Burnout in Israeli Parents of Children with ASD During Wartime: The Role of Child Behavior, Parental Emotion Regulation, Stress, and Social Support

During emergencies like wartime, parents of children with Autism Spectrum Disorder (ASD) face heightened challenges, potentially leading to Parental Burnout (PB). Wartime conditions can exacerbate children's behavioral difficulties, contributing to PB. Protective factors such as successful Emotional Regulation (ER) and perceived social support may mitigate PB. This study aims to compare child behavioral problems, parental ER difficulties, perceived social support, stress, and PB between parents of children with ASD and Typical Development (TD) during wartime. It also investigates how ER difficulties, perceived social support, and stress moderate the relationship between child behavioral problems and PB. The study included 213 Israeli parents: 101 parents of children diagnosed with ASD and 112 parents of TD children. Participants were recruited during the "Swords of Iron" War using purposive sampling via online platforms. Findings indicate that children with ASD exhibited higher levels of behavioral problems, and their parents experienced increased difficulties in ER, stress, and PB, alongside decreased perceived social support compared to parents of TD children. Moderation analysis revealed that ER difficulties, perceived social support, and stress moderated the direct association between child behavioral problems and PB specifically among parents of TD children. This study underscores the heightened vulnerability of parents with ASD-diagnosed children during wartime, emphasizing the importance of understanding how these circumstances impact parental well-being and available resources. Effective interventions should target enhancing ER, social support, and addressing parental stress, PB, and child behavioral issues, underscoring the need for prioritized services despite wartime challenges.

The Impact of Dog-Assisted Therapy Among Children and Adolescents with Autism Spectrum Disorder: A Systematic Review

BACKGROUND AND OBJECTIVES

Animal-assisted therapies have been utilized in various profiles to improve people's quality of life. This systematic review aims to assess the impact of dog-assisted therapies (DAT) on children and adolescents with Autism Spectrum Disorder (ASD). The benefits provided, the feasibility of implementation, and potential limitations are analysed.

METHODS

An exhaustive search was carried out in the following databases: Web of Science (WoS), Scopus, ERIC, PubMed, PubPsych, CINAHL, PsycInfo and Dialnet. The procedure was preregistered on PROSPERO.

RESULTS

This review included 19 scientific articles. Of these, 84% suggest that DAT has a positive impact on communication and social interaction during the development of children and adolescents diagnosed with ASD. The dog is often perceived as a communication facilitator that serves as a reinforcer, capturing the individual's attention. Emotional benefits have also been reported, including reducing stereotyped and self-harming behaviours. Additionally, an increase in smiling frequency and self-esteem levels was observed.

CONCLUSIONS

These findings highlight the potential of DAT as a component of socio-educational intervention for children and adolescents diagnosed with ASD. However, further research is necessary due to the limited sample sizes in the studies reviewed.

Bruxism associated with short sleep duration in children with autism spectrum disorder: The Japan Environment and Children's Study

Bruxism, the involuntary activity of masticatory muscles, is common among individuals with autism spectrum disorders (ASD). Although bruxism is bidirectionally associated with sleep issues, whether an infant's sleep duration contributes to the development of bruxism remains unknown. In this study, a dataset (n = 83,720) obtained from the Japan Environment and Children's Study, a nationwide birth cohort study, was subjected to multiple imputations using logistic regression analysis with adjustments for several maternal and child-related variables. The aim of this study was to assess whether shorter sleep duration in the neonatal period additively affected the high prevalence of parent-reported bruxism (PRB) among children with ASD. The prevalences of ASD and PRB in the participants were 1.2% and 7.2%, respectively, and the odds ratio of the increased risk of PRB prevalence in individuals with ASD (95% confidence interval) was 1.59 (1.31-1.94) after covariate adjustments. Importantly, shorter sleep duration in the neonatal period (at one month of age) was significantly associated with an increased risk of PRB prevalence in individuals with ASD. The increased occurrence of bruxism, known to be highly prevalent among children with ASD, is associated with shorter sleep duration, particularly in the neonatal stage. Based on our results, a better understanding of the development of bruxism in individuals with ASD would provide valuable information for the prevention of oral diseases.

Enhancing ASD detection accuracy: a combined approach of machine learning and deep learning models with natural language processing

Purpose

The main aim of our study was to explore the utility of artificial intelligence (AI) in diagnosing autism spectrum disorder (ASD). The study primarily focused on using machine learning (ML) and deep learning (DL) models to detect ASD potential cases by analyzing text inputs, especially from social media platforms like Twitter. This is to overcome the ongoing challenges in ASD diagnosis, such as the requirement for specialized professionals and extensive resources. Timely identification, particularly in children, is essential to provide immediate intervention and support, thereby improving the quality of life for affected individuals.

Methods

We employed natural language processing (NLP) techniques along with ML models like decision trees, extreme gradient boosting (XGB), k-nearest neighbors algorithm (KNN), and DL models such as recurrent neural networks (RNN), long short-term memory (LSTM), bidirectional long short-term memory (Bi-LSTM), bidirectional encoder representations from transformers (BERT and BERTweet). We extracted a dataset of 404,627 tweets from Twitter users using the platform's API and classified them based on whether they were written by individuals claiming to have ASD (ASD users) or by those without ASD (non-ASD users). From this dataset, we used a subset of 90,000 tweets (45,000 from each classification group) for the training and testing of these models.

Results

The application of our AI models yielded promising results, with the predictive model reaching an accuracy of almost 88% when classifying texts that potentially originated from individuals with ASD.

Conclusion

Our research demonstrated the potential of using AI, particularly DL models, in enhancing the accuracy of ASD detection and diagnosis. This innovative approach signifies the critical role AI can play in advancing early diagnostic techniques, enabling better patient outcomes and underlining the importance of early identification of ASD, especially in children.

Autism Spectrum Disorder and Associated Factors in Children in Spain, 2017: Population-Based Cross-Sectional Study

OBJECTIVES

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with biological, multicausal and polygenic origins. The true prevalence of ASD has not been clearly established. The aim of this study was to estimate the prevalence of ASD in children aged 3 to 14 years in Spain and to analyze the factors associated with it.

METHODS

A cross-sectional observational study using data from the 2017 National Survey of Health in Minors in Spain. Primary outcome was the diagnosis of ASD, and sociodemographic, behavioral, health-related, the use of health services, household and medication use variables was analyzed. Multivariable logistic regression model with a correction for modelling rare events was fitted. Complex sampling was undertaken, using the survey elevation factor in the analysis.

RESULTS

A total of 4409 children were included, and there were 26 children with ASD, for a prevalence of 0.59%, representing 29,143 children with ASD. Factors significantly associated were male sex, having visited a psychologist, and/or a speech therapist in the past year, presenting probable problems with peers, antisocial behavior, taking antibiotics and taking other medications.

CONCLUSION

The findings of this study may be useful to inform health policies and develop strategic plans to identify and address the needs of children with ASD.

Relationships between Gut Microbiota and Autism Spectrum Disorders: Development and Treatment

Many studies have demonstrated the impact of intestinal microbiota on normal brain development. Moreover, the gut microbiota (GM) is impacted by multiple endogenous and environmental factors that may promote gut dysbiosis (GD). An increasing number of studies are investigating the possible role of the GD in the development of neurological and behavioral disorders. For autism spectrum disorders (ASD), specific intestinal bacterial signatures have been identified, knowing that gastrointestinal symptoms are frequently found in ASD. In this review, the peri and post-natal factors modulating the GM are described and the specific gut bacterial signature of ASD children is detailed. Through bidirectional communication between the GM and the brain, several mechanisms are involved in the development of ASD, such as cytokine-mediated neuroinflammation and decreased production of neuroprotective factors such as short-chain fatty acids by the GM. Imbalance of certain neurotransmitters such as serotonin or gamma-aminobutyric acid could also play a role in these gut-brain interactions. Some studies show that this GD in ASD is partly reversible by treatment with pre- and probiotics, or fecal microbiota transplantation with promising results. However, certain limitations have been raised, in particular concerning the short duration of treatment, the small sample sizes and the diversity of protocols. The development of standardized therapeutics acting on GD in large cohort could rescue the gastrointestinal symptoms and behavioral impairments, as well as patient management.

Dental Adaptation Strategies for Children with Autism Spectrum Disorder-A Systematic Review of Randomized Trials

Background: Children with Autism Spectrum Disorder (ASD) often struggle with dental care due to sensory sensitivities and behavioral issues, increasing their risk for oral health problems. Adaptation strategies such as visual aids, video modeling, and sensory-adapted environments aim to improve their dental experiences. Methods: A systematic review of randomized controlled trials (RCTs) was conducted according to PRISMA 2020 guidelines using the PubMed, Scopus, Embase, and Cochrane databases. Of the 1072 records screened, nine RCTs were included in the analysis. Studies included children with ASD under 18 years and compared dental adaptation techniques with traditional care. The risk of bias and study quality were assessed. The quality of evidence for the results was determined using the GRADE tool. Results: Nine RCTs with sample sizes ranging from 25 to 138 participants showed significant improvements in oral hygiene, reduced anxiety, and increased cooperation. Video modeling and sensory-adapted environments were particularly effective in lowering distress during dental visits. Conclusions: Dental adaptation strategies, especially video modeling and sensory-adapted environments, effectively improve oral health outcomes and reduce anxiety in children with ASD. More research is needed to explore the long-term effects and include children with severe ASD.

The associations between child behavioral problems, parents' emotional regulation difficulties, and parental burnout among Israeli parents of children with autism during wartime

Introduction

Parents of children with Autism Spectrum Disorder (ASD) face heightened challenges during crises like war, leading to parental burnout (PB). Wartime demands may exacerbate the children's behavioral difficulties, which associated with PB. Successful emotional regulation (ER) is considered a protective factor for PB. This study aimed to explore the associations between the child behavioral problems, parent's ER difficulties and PB among parents of children ASD during wartime.

Methods

92 parents completed demographic, Parental Burnout, Difficulties in Emotion Regulation, and Child Aberrant Behavior questionnaires. In addition, 18 parents of children with ASD aged 6-21 were semi-interviewed.

Results

During wartime, child behavioral problems and parents' ER difficulties were positively correlated with PB, contributing beyond background characteristics and other changes following the war. Parent ER difficulties serve as a mediation variable and did not function as a moderation variable between child behavioral problems and PB.

Discussion

This study emphasizes the increased vulnerability of parents of children with ASD during wartime, highlighting the need for a deeper understanding of how these circumstances affect parental risk and resources. Effective interventions should target emotional regulation and address child behavioral issues, necessitating prioritized support for affected families despite wartime challenges.

Aquatic Therapy in Children and Adolescents with Disabilities: A Scoping Review

Globally, around 1 in 10 children aged 0-17 years have moderate-to-severe disabilities. The aquatic environment provides hydrostatic and hydrodynamic characteristics that make exercise and therapy feasible for children and adolescents with disabilities. The objective of this scoping review is to understand the extent and type of evidence in relation to the use of aquatic therapy in children and adolescents with disabilities. The eligibility criteria were as follows: participants-children and/or adolescents with disabilities aged from 6 to 18 years old; concept-aquatic therapy interventions; context-any available setting. The databases searched included MEDLINE, CINAHL, EMBASE, PsycINFO, AMED, Eric, Scopus, Web of Science, Epistemonikos, and one register, Cochrane Central Register of Controlled Trials. In total, 52 reports met the inclusion criteria. Most of the studies included children/adolescents with autism spectrum disorder (ASD; 46.7%)-442 participants in 21 studies in total. The majority of interventions were based on aquatic exercise (35%). Most often, interventions were conducted for 8 weeks, with 2 sessions a week lasting 60 min. The most common type of intervention for children and adolescents with ASD and Down syndrome was swimming. Participants with attention deficit hyperactivity disorder, neuromuscular disorders, and cerebral palsy were more often treated with aquatic exercises. This scoping review could guide practitioners, clinicians, and researchers on what type, setting, and content of aquatic therapy interventions, including exercise types, intervention duration, number of sessions, frequency, facility, and provider, are used with children and adolescents with disabilities.

Development of personalized profiles of students with autism spectrum disorder for interactive interventions with robots to enhance language and social skills

The inclusion of students with autism spectrum disorder (ASD) in mainstream education (primary and secondary, in the range of 4-5 to 8-10 years old) is a complex task that has long challenged both educators and health professionals. However, the correct use of digital technologies such as personalization settings and interaction with robots has clearly shown how these new technologies can benefit ASD students. However, it is essential to characterize the profile, problems, and needs of each student, since it is not possible to generalize an accessible approach for all users. The work presented shows the creation and validation, through pilot tests, of an instrument that outlines the main needs of a student with ASD, based on behavioral variables. In a later phase, instructional sequences will be designed and adapted through digital tablets and interaction with a robot to improve specific aspects identified in the initial profile. The results demonstrate the method's ability to assess and prioritize profiles satisfactorily which helps create a design adjusted to each student. The first pilot tests have been well received by ASD students, who have shown increased interest in the contents and methods used in this approach. Motivation levels and engagement have also increased, and social interactions with their peers have improved.

Nigerian Hospital and Community Pharmacists' Knowledge, Awareness, and Perceptions of Autism Spectrum Disorders

Background

Pharmacists can play a role in enhancing treatment outcomes of autistic people, but they must possess sufficient knowledge and awareness of autism spectrum disorders (ASD). Current evidence is scant among Nigerian pharmacists. The objectives of this study were to: (1) Describe and compare Nigerian hospital and community pharmacists' ASD knowledge, awareness, and perceptions; (2) Determine if there is a significant correlation between ASD knowledge, awareness, and perceptions; (3) Determine if demographic and practice-related factors are significantly related to pharmacists' ASD awareness.

Method

Hospital and community pharmacists were administered a self-report survey to assess ASD knowledge and awareness, as well as confidence in caring for autistic people, and perceived benefits of ASD training and care. Data were collected from August to December 2021 and analyzed using inferential and descriptive statistics. Cronbach's alphas were used to assess reliability.

Results

Of respondents, (Total N = 383; N = 201 hospital pharmacists from various states) and N = 182 community pharmacists in Lagos state) community pharmacists had significantly higher mean knowledge than hospital pharmacists (58.10% ± 19.00% vs 53.20% ± 20.10%; P = .016). Overall mean awareness score was 2.90 ± 0.80, with no significant difference between community and hospital pharmacists (P = .096). Perception regarding ASD continuing education (CE) was strongly correlated with the perceived benefits of pharmacy services to autistic people in Nigeria (r = .69; P < .0001). Additionally, awareness was positively correlated with knowledge (r = .47, P < .0001) and perceived confidence in ASD medication counseling (r = .54, P < .0001). Multivariate analysis revealed that being a hospital pharmacist, having courses on ASD during pharmacy degree programs, undergoing ASD CE, and having <5 years of practice experience were significantly (P < 0.05) associated with higher ASD awareness.

Conclusion

Respondents had suboptimal knowledge and awareness of ASD. Including ASD in the pharmacy curriculum and providing CE programs may help improve pharmacists' ability to provide more optimal patient care services for autistic people.

Amelioration of propionic acid-induced autism-like behaviors in rats by fenofibrate: A focus on reduction of brain galectin-3 levels

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impaired social interactions and repetitive behaviors. This study examines the effects of fenofibrate on a propionic acid (PPA)-induced rat model of ASD, focusing on behavioral changes, inflammatory markers, and histological findings.

MATERIALS AND METHODS

Thirty male Wistar rats were divided into three groups: a control group, a group receiving PPA and saline, and a group treated with PPA and fenofibrate for 15 days. Behavioral assessments, including the three-chamber sociability test, open-field test, and passive avoidance learning, were conducted. Biochemical analyses measured TNF-α, NGF, IL-17, IL-2, and galectin-3 levels in brain tissues. Histological evaluations focused on Purkinje neuron counts in the cerebellum and neuronal changes in the CA1 and CA3 regions of the hippocampus, along with glial fibrillary acidic protein (GFAP) levels.

RESULTS

Fenofibrate treatment significantly improved behavioral outcomes, reducing autism-like behaviors compared to the PPA/saline group. Biochemically, the PPA/saline group showed elevated levels of malondialdehyde, TNF-α, IL-2, IL-17, and galectin-3, which were reduced following fenofibrate treatment. Histologically, the PPA/saline group exhibited fewer, dysmorphic Purkinje neurons and increased glial activity in the CA1 region, both of which were ameliorated by fenofibrate treatment.

CONCLUSION

Fenofibrate shows promise in mitigating autism-like behaviors in a rat model of ASD, likely due to its antioxidative and neuroprotective properties, which contribute to preserving neuronal integrity and reducing inflammation.

Evaluation of the Efficacy of a Full-Spectrum Low-THC Cannabis Plant Extract Using In Vitro Models of Inflammation and Excitotoxicity

Evidence has accumulated that Cannabis-derived compounds have the potential to treat neuroinflammatory changes present in neurodevelopmental conditions such as autism spectrum disorder. However, research is needed on the specific brain health benefits of strains of whole Cannabis extract that are ready for commercial production. Here, we explore the anti-inflammatory and neuroprotective effects of NTI-164, a genetically unique high-cannabidiol (CBD), low-Δ9-tetrahydrocannabinol extract, and also CBD alone on BV-2 microglia and SHSY-5Y neurons. Inflammation-induced up-regulation of microglial inflammatory markers was significantly attenuated by NTI-164, but not by CBD. NTI-164 promoted undifferentiated neuron proliferation and differentiated neuron survival under excitotoxic conditions. These effects suggest the potential for NTI-164 as a treatment for neuropathologies.

Intercontinental insights into autism spectrum disorder: a synthesis of environmental influences and DNA methylation

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder characterized by a broad range of symptoms. The etiology of ASD is thought to involve complex gene-environment interactions, which are crucial to understanding its various causes and symptoms. DNA methylation is an epigenetic mechanism that potentially links genetic predispositions to environmental factors in the development of ASD. This review provides a global perspective on ASD, focusing on how DNA methylation studies may reveal gene-environment interactions characteristic of specific geographical regions. It delves into the role of DNA methylation in influencing the causes and prevalence of ASD in regions where environmental influences vary significantly. We also address potential explanations for the high ASD prevalence in North America, considering lifestyle factors, environmental toxins, and diagnostic considerations. Asian and European studies offer insights into endocrine-disrupting compounds, persistent organic pollutants, maternal smoking, and their associations with DNA methylation alterations in ASD. In areas with limited data on DNA methylation and ASD, such as Africa, Oceania, and South America, we discuss prevalent environmental factors based on epidemiological studies. Additionally, the review integrates global and country-specific prevalence data from various studies, providing a comprehensive picture of the variables influencing ASD diagnoses over region and year of assessment. This prevalence data, coupled with regional environmental variables and DNA methylation studies, provides a perspective on the complexities of ASD research. Integrating global prevalence data, we underscore the need for a comprehensive global understanding of ASD's complex etiology. Expanded research into epigenetic mechanisms of ASD is needed, particularly in underrepresented populations and locations, to enhance biomarker development for diagnosis and intervention strategies for ASD that reflect the varied environmental and genetic landscapes worldwide.

Challenges of Alternative Teaching-Learning Faced by Indian Parents of People with Autism Spectrum Disorder During Pandemic Emergency

The COVID-19 pandemic stretched between 2020 and 2021 and witnessed impactful changes in the education system inclusive of the special education sector. The special education sector selected online teaching-learning to continue the studies of their students with the help of the parents. The study aimed to find out the challenges faced by parents of people with autism enrolled in special schools who attended online classes along with their children and supported their teaching-learning. The mixed method study (sequential explanatory design) opted for quantitative phases followed by a qualitative phase for further in-depth exploration of the focus area. The quantitative phase consists of 100 participant parents and the qualitative phase consists of 15 participant parents recruited from phase one of the study through purposive sampling based on the inclusion and exclusion criteria. The data were collected via web forms and online interviews were recorded. The univariate analysis was used for the quantitative phase whereas thematic analysis was used for the qualitative phase. The parents had to manage office work, childcare, assisting in online classes, handling the psychological and behavioral issues of the child. Even challenges like learning new technology, managing additional expenses and personal stress were reported. The enormous efforts of the parents helped to overcome many of the challenges and achieve positive learning outcomes. Nevertheless, some recommendations like arrangement of parental workshops, increase in tech education and occasional hybrid mode of learning is suggested.

Virtual Screening Approaches to Identify Promising Multitarget-Directed Ligands for the Treatment of Autism Spectrum Disorder

Autism spectrum disorder is a complex neurodevelopmental disorder. The available medical treatment options for autism spectrum disorder are very limited. While the etiology and pathophysiology of autism spectrum disorder are still not fully understood, recent studies have suggested that wide alterations in the GABAergic, glutamatergic, cholinergic, and serotonergic systems play a key role in its development and progression. Histamine neurotransmission is known to have complex interactions with other neurotransmitters that fit perfectly into the complex etiology of this disease. Multitarget-directed compounds with an affinity for the histamine H3 receptor indicate an interesting profile of activity against autism spectrum disorder in animal models. Here, we present the results of our research on the properties of (4-piperazin-1-ylbutyl)guanidine derivatives acting on histamine H3 receptors as potential multitarget ligands. Through the virtual screening approach, we identified promising ligands among 32 non-imidazole histamine H3 receptor antagonists/inverse agonists with potential additional activity against the dopamine D2 receptor and/or cholinesterases. The virtual screening protocol integrated predictions from SwissTargetPrediction, SEA, and PPB2 tools, along with molecular docking simulations conducted using GOLD 5.3 and Glide 7.5 software. Among the selected ligands, compounds 25 and 30 blocked radioligand binding to the D2 receptor at over 50% at a screening concentration of 1 µM. Further experiments allowed us to determine the pKi value at the D2 receptor of 6.22 and 6.12 for compounds 25 and 30, respectively. Our findings suggest that some of the tested compounds could be promising multitarget-directed ligands for the further research and development of more effective treatments for autism spectrum disorder.

Evaluating the impact of needs assessment models on autistic children's participation in the habilitation process: protocol for a prospective observational study

INTRODUCTION

The rising prevalence of autism spectrum disorder (ASD) among children poses significant challenges for healthcare services. Research has underscored the crucial role of children's involvement in their healthcare. However, due to the intricate nature of ASD, marked by communication and social interaction differences, healthcare providers face challenges in tailoring their services to accommodate these children. This project aims to explore the impact of two distinct needs assessment models on children's participation in the needs assessment process.

METHODS AND ANALYSIS

We will conduct a prospective observational study comparing responses from children subjected to two different needs assessment procedures: survey-based and meeting-based. Supplementary data will be collected from the children's parents/guardians and healthcare professionals. Data collection methods will include questionnaires, interviews and document analysis of individual habilitation plans. We aim to recruit 120 children aged 7-17 diagnosed with ASD but without intellectual disability, with 60 undergoing the survey-based needs assessment and 60 undergoing the meeting-based assessment. The primary outcome measure will be the perception of participation in the needs assessment procedure. Secondary outcomes will include the children's quality of life and mental health; the parents' knowledge of their child's strengths, abilities and special needs; and the parents' perception of the quality of collaboration with the healthcare team.

ETHICS AND DISSEMINATION

The study received ethics approval from the Swedish Ethical Review Authority on 4 March 2024 (reference number 2024-00227-01). All children and their caregivers will receive both verbal and written information about the study before being asked to provide written informed consent to participate. The findings will be disseminated through publication in peer-reviewed journals and presentation at conferences. Additionally, a popular science report summarising the data and its interpretation will be published.

TRIAL REGISTRATION NUMBER

NCT06381856.

Support for Children With Neurodevelopmental Disorders: A Qualitative Study Based on Interviews With School Nurse-Teachers

The role of school nurse-teachers (SNTs) in supporting children with neurodevelopmental disorders (CNDs) in compulsory education schools has not been clarified. This study aimed to explore how these professionals manage challenges and provide tailored care for CNDs in such settings. We conducted a qualitative analysis of semi-structured interviews with experienced SNTs. The findings indicate that SNTs employ various strategies, including making environmental adjustments for children with sensory hypersensitivity, communicating clearly according to individual traits, and collaborating with other educators and parents to address the difficulties faced by CNDs. These approaches should be integrated into routine SNT practices to support children's health and improve their quality of life.

Sublime and extended reality experiences to enhance emotional wellbeing for autistic people: A state of the art review and narrative synthesis

BACKGROUND

Sublime is a centuries old concept of emergent experience arising from immense and threatening awareness provoked by overwhelming fear and dread when faced with an incomprehensible situation as is common to autistic people. Extended Reality (XR) technologies have been used since the mid-1990s, in regulating emotions, behaviour and supporting social skill development for autistic people.

AIMS

To understand utility of XR technologies in creating immersive experiences for autistic people to alleviate anxiety and the relationship to the sublime.

METHOD

A State of the Art literature review and narrative synthesis was conducted. PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, Web of Science were searched with terms Autism AND Technology. In addition, fields of digital technologies and wellbeing, digital art and mental health, generative arts and the sublime were explored through web searches of grey literature, conversations with digital designers and explorations of extended reality platforms. No time limits were placed. Searches were done in English. Papers were screened and shortlisted using the inclusion criteria applied by two reviewers.

RESULTS

Fifty-eight papers/articles met the preliminary inclusion criteria for in-depth review of which 31 were found suitable for the narrative synthesis related to XR technologies and sublime experiences as related to autistic people. Narrative synthesis lent itself to four themes that is current utility of XR Technologies in autism, the impact of immersive experiences on Behavioural, phenomenological and biological markers of autistic people, the Benefits of increased sensory stimulation using XR on autism and an inquiry into the potential of the sublime for autism.

CONCLUSIONS

Mixed reality environments that experiment with a broad range of XR technologies including incorporating notions of the sublime, might be beneficial in reducing emotional dysregulation and improving social development in autistic people especially if co-designed with them.

Salivary IL-1 Beta Level Associated with Poor Sleep Quality in Children/Adolescents with Autism Spectrum Disorder

BACKGROUND

Sleep disorders are common in youths with autism spectrum disorders. Inflammatory cytokines such as Il-1 beta and Il-6 in saliva have been associated with alterations in sleep quality in various conditions. We assessed whether there were associations between the salivary concentration of IL-1 beta and IL-6 and sleep quality in youths with ASD versus typically developing (TD) age- and gender-matched youths.

METHOD

Forty children and adolescents with ASD or TD participated in this study (20% females). Their parents answered the items of a validated questionnaire on sleep quality (Pittsburgh Sleep Quality Index).

RESULTS

The mean Pittsburgh score was significantly higher (i.e., the quality of sleep was poorer) in the ASD group (8.68 ± 0.35 (SEM), ranging from 7 to 12 points), compared to the TD group (7.35 ± 0.54 (SEM), ranging from 2 to 12 points) (p = 0.02, Mann-Whitney U test). There were no significant differences in the salivary concentration of Il-1 beta and IL-6 receptor between the two groups, but salivary IL-1 beta concentration was inversely associated with poor sleep quality in the ASD group. No associations between the salivary Il-6 concentration and sleep quality were found in either group. Linear regression analysis by separate groups revealed significant associations between the sleep quality score and the concentration of IL-1 beta in the ASD group (p = 0.01, OR = -0.53, 95% CI -0.008-0.001). In contrast, no significant associations were observed in the TD group, or for IL-6 in either group. No significant effects of sex, age, or use of psychotropic medications were found.

CONCLUSIONS

Children and adolescents with ASD showed significantly poorer sleep quality based on their parents' reports compared to the TD group, and the salivary IL-1 beta concentration was inversely associated with sleep quality only in the ASD group. Further studies on the associations between inflammatory cytokines and sleep in ASD are needed.

The Cerebellum-Ventral Tegmental Area Microcircuit and Its Implications for Autism Spectrum Disorder: A Narrative Review

The cerebellum has long been implicated in the etiopathogenesis of autism spectrum disorder (ASD), and emerging evidence suggests a significant contribution by reciprocal neural circuits between the cerebellum and ventral tegmental area (VTA) in symptom expression. This review provides a concise overview of morphological and functional alterations in the cerebellum and VTA associated with ASD symptoms, primarily focusing on human studies while also integrating mechanistic insights from animal models. We propose that cerebello-VTA circuit dysfunctional is a major contributor to ASD symptoms and that these circuits are promising targets for drugs and therapeutic brain stimulation methods.

Heterogeneity and convergence across seven neuroimaging modalities: a review of the autism spectrum disorder literature

Background

A growing body of literature classifies autism spectrum disorder (ASD) as a heterogeneous, complex neurodevelopmental disorder that often is identified prior to three years of age. We aim to provide a narrative review of key structural and functional properties that differentiate the neuroimaging profile of autistic youth from their typically developing (TD) peers across different neuroimaging modalities.

Methods

Relevant studies were identified by searching for key terms in PubMed, with the most recent search conducted on September 1, 2023. Original research papers were included if they applied at least one of seven neuroimaging modalities (structural MRI, functional MRI, DTI, MRS, fNIRS, MEG, EEG) to compare autistic children or those with a family history of ASD to TD youth or those without ASD family history; included only participants <18 years; and were published from 2013 to 2023.

Results

In total, 172 papers were considered for qualitative synthesis. When comparing ASD to TD groups, structural MRI-based papers (n = 26) indicated larger subcortical gray matter volume in ASD groups. DTI-based papers (n = 14) reported higher mean and radial diffusivity in ASD participants. Functional MRI-based papers (n = 41) reported a substantial number of between-network functional connectivity findings in both directions. MRS-based papers (n = 19) demonstrated higher metabolite markers of excitatory neurotransmission and lower inhibitory markers in ASD groups. fNIRS-based papers (n = 20) reported lower oxygenated hemoglobin signals in ASD. Converging findings in MEG- (n = 20) and EEG-based (n = 32) papers indicated lower event-related potential and field amplitudes in ASD groups. Findings in the anterior cingulate cortex, insula, prefrontal cortex, amygdala, thalamus, cerebellum, corpus callosum, and default mode network appeared numerous times across modalities and provided opportunities for multimodal qualitative analysis.

Conclusions

Comparing across neuroimaging modalities, we found significant differences between the ASD and TD neuroimaging profile in addition to substantial heterogeneity. Inconsistent results are frequently seen within imaging modalities, comparable study populations and research designs. Still, converging patterns across imaging modalities support various existing theories on ASD.

The Relationship between Early Exposure to General Anesthesia and Neurobehavioral Deficits

BACKGROUND

In contemporary medical practice, general anesthesia plays an essential role in pediatric surgical procedures. While modern anesthetic protocols have demonstrated safety and efficacy across various pathological conditions, concerns persist regarding the potential neurotoxic effects associated with early exposure to general anesthesia.

SUMMARY

Current research primarily examines the neurocognitive developmental impacts, with limited focus on neurobehavioral developmental disorders. This review presents a comprehensive analysis of clinical trial results related to five critical neurobehavioral developmental disorders: fine motor disability, attention-deficit hyperactivity disorder, impulse control disorders, autism spectrum disorder, and developmental coordination disorder. Furthermore, this review synthesizes insights from basic research on the potential toxicological mechanisms of general anesthetic agents that could influence clinical neurobehavioral changes. These findings provide valuable guidance for the prudent and safe utilization of anesthetic agents in pediatric patients.

KEY MESSAGES

This review explores the potential connections between general anesthesia and five neurobehavioral disorders, highlighting the importance of cautious anesthetic use in children in light of current research findings.

Managing Aggressive Behavior in Adolescents With Autism Spectrum Disorder: Pharmacological and Non-Pharmacological Approaches

Adolescents diagnosed with autism spectrum disorder (ASD) often encounter significant challenges, particularly aggressive behaviors that persist into adulthood and profoundly affect their daily functioning and quality of life. These behaviors not only pose hurdles for affected individuals but also present considerable challenges for caregivers and families. Managing aggression in adolescents with ASD requires comprehensive treatment approaches encompassing both non-pharmacological and pharmacological interventions. This paper reviews current interventions that have proven to be effective through empirical studies in managing aggression among adolescents with ASD. By synthesizing evidence-based practices, this study underscores the importance of a multidisciplinary approach involving medical, psychological, and educational interventions to effectively manage aggression among adolescents with ASD. It aimed to inform clinicians, educators, and caregivers of practical strategies and evidence-based interventions to address aggression in this population.

Demographic and autism characteristics as predictors of age of autism diagnosis of individuals with autism in Paraguay

LAY ABSTRACT

Autism is a lifelong condition characterized by repetitive behaviors and social communication differences. The reported cases of autism increased globally in the past years. Detecting autism early and providing appropriate supports promptly are crucial for better outcomes. Yet, little research focuses on what factors interplay in the diagnostic process of autistic children in Paraguay. We gathered data from 176 caregivers of autistic children under 18 years in Paraguay. Through a detailed analysis, we found that child's age, child's age at the caregiver's first concerns about their development, and the child's verbal skills are key in predicting the age of autism diagnosis in Paraguay. Educating caregivers and professionals about autism and social communication development can help identify autism early and provide timely support.

Genetic etiology of autism spectrum disorder in the African population: a scoping review

Background

Autism spectrum disorder (ASD) is a neurodevelopmental disorder (NDD) characterized by significant impairments in social, communicative, and behavioral abilities. However, only a limited number of studies address the genetic basis of ASD in the African population. This study aims to document the genes associated with ASD in Africa and the techniques used to identify them. Additionally, genes identified elsewhere but not yet in Africa are also noted.

Methods

Online databases such as Wiley Online Library, PubMed, and Africa Journal Online were used. The review was conducted using the keyword related to genetic and genomic ASD study in the African population.

Result

In this scoping review, 40 genetic studies on ASD in Africa were reviewed. The Egyptian and South African populations were the most studied, with 25 and 5 studies, respectively. Countries with fewer studies included Tunisia (4), East African countries (3), Libya (1), Nigeria (1), and Morocco (1). Some 61 genes responsible for ASD were identified in the African population: 26 were identified using a polymerase chain reaction (PCR)-based method, 22 were identified using sequencing technologies, and 12 genes and one de novo chromosomal aberration were identified through other techniques. No African study identified any ASD gene with genome-wide association studies (GWAS). Notably, at least 20 ASD risk genes reported in non-African countries were yet to be confirmed in Africa's population.

Conclusion

There are insufficient genetic studies on ASD in the African population, with sample size being a major limitation in most genetic association studies, leading to inconclusive results. Thus, there is a need to conduct more studies with large sample sizes to identify other genes associated with ASD in Africa's population using high-throughput sequencing technology.

Socio-medical Factors Associated with Neurodevelopmental Disorders on the Kenyan Coast

Background

Neurodevelopmental disorders (NDDs) are a group of conditions with their onset during the early developmental period and include conditions such as autism, intellectual disability and attention deficit hyperactivity disorder (ADHD). Occurrence of NDDs is thought to be determined by both genetic and environmental factors, but data on the role of environmental risk factors for NDD in Africa is limited. This study investigates environmental influences on NDDs in children from Kenya. This case-control study compared children with NDDs and typically developing children from two studies on the Kenyan coast that did not overlap.

Methods and Findings

We included 172 of the study participants from the Kilifi Autism Study and 151 from the NeuroDev Study who had a diagnosis of at least one NDD and 112 and 73 with no NDD diagnosis from each study, respectively. Potential risk factors were identified using unadjusted univariable analysis and adjusted multivariable logistic regression analysis. Univariable analysis in the Kilifi Autism Study sample revealed hypoxic-ischaemic encephalopathy conferred the largest odds ratio (OR) 10.52 (95%CI 4.04 - 27.41) for NDDs, followed by medical complications during pregnancy (gestational hypertension & diabetes, eclampsia, and maternal bleeding) OR: 3.17 (95%CI 1.61 - 6.23). In the NeuroDev study sample, labour and birth complications (OR: 7.30 (2.17 - 24.61)), neonatal jaundice (OR: 5.49 (95%CI 1.61 - 18.72)) and infection during pregnancy (OR: 5.31 (1.56 - 18.11)) conferred the largest risk associated with NDDs. In the adjusted analysis, seizures before age 3 years in the Kilifi Autism study and labour and birth complications in the NeuroDev study conferred the largest increased risk. Higher parity, the child being older and delivery at home were associated with a reduced risk for NDDs.

Conclusion

Recognition of important risk factors such as labour and birth complications could guide preventative interventions, developmental screening of at-risk children and monitoring progress. Further studies examining the aetiology of NDDs in population-based samples, including investigating the interaction between genetic and environmental factors, are needed.

Exploring the landscape of adult autism research in psychology: a bibliometric and network analysis

The global prevalence of autism spectrum disorder (ASD) is increasing. ASD manifests with persistent social communication and interaction challenges, limited interests, and repetitive behaviors. As the scientific literature on ASD in adults varies greatly, mapping the recent global research becomes valuable for enhancing comprehension of this subject. This study aims to map recent global scientific publications on ASD in adults. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, bibliometrics, and network analyses, we assessed 850 articles indexed in the Web of Science Core Collection between 2013 and 2022 assigned to the research area of psychology. Findings indicate an annual average growth of 11.69%. Key keywords include Emotion, Anxiety, and Depression, with Anxiety, Depression, and Mental Health as central nodes in the network. Rehabilitation, Behavioral Sciences, and Psychiatry frequently co-occur, and Psychology, Psychiatry, and 'Neurosciences and Neurology' are central nodes in the network of research areas. The United States of America and the United Kingdom lead in publications, with the United Kingdom being the most central country in the network. King's College London and the University of California are the main research organizations, with King's College London as the central node in the network. The American Psychiatric Association's DSM-5-TR was the most cited reference in the period. This comprehensive analysis contributes to understanding the landscape of ASD research in adults, providing insights for future research and fostering collaborations.

Scoping review on mental health standards for Black youth: identifying gaps and promoting equity in community, primary care, and educational settings

BACKGROUND

Youth mental health is a growing concern in research, practice, and policy. Practice standards, guidelines, or strategies provide an invisible infrastructure that fosters equity, quality, and safety, potentially addressing inconsistencies and more effectively attending to the mental wellness of Black youth as a particular population of concern. This scoping review aimed to address the following question: What standards exist for the delivery of mental health services to Black youth in community, primary care, and educational settings? Due to a limited initial search yield on publications about standards for the delivery of mental health services for Black youth population, our goal was then to identify and map mental health standards, recommendations, or guidelines for the delivery of mental health services using the same settings to all youth.

METHODS

Searches were conducted in various databases, including PubMed/MEDLINE, PsycINFO, Embase, SocINDEX, CINAHL, Gender Studies Database, Social Services Abstracts, Sociological Abstracts, Scopus, Web of Science, and Google Scholar. Screening was independently conducted by two reviewers, with disagreements resolved by a third. Information extraction was performed by two independent reviewers.

RESULTS

Out of the 2,701 screened publications, 54 were included in this scoping review. Among them, 38.9% were published between 2020 and 2023, with 40.7% originating from the United States of America, 20.4% from the United Kingdom, and 13% from Canada. Concerning the settings, 25.9% of the publications focused on primary care, 24.1% on health care services, 20.4% on educational settings, and 3.7% on the community. Additionally, 25.9% were classified as general because recommendations were applicable to various settings. Attention-deficit/hyperactivity disorder (11.1%) was the most frequently considered specific condition, followed by autism spectrum disorder (9.3%) and depression (9.3%). However, 31.5% of the included references addressed mental health in general. Only three references provided specific recommendations for the Black population.

CONCLUSIONS

Recommendations, guidelines, or standards for Black youth mental health services in community, primary care, or educational settings are scarce and limited to North American countries. This scoping review emphasizes the need to consider ethnicity when developing guidelines or standards to improve racial equity and reduce disparities in access to mental health services.

The Face of Autism in Israel

This article seeks to offer a comprehensive perspective on autism in Israel, aligning with global reports. It aims to serve as a foundational resource for policymakers in developing relevant support and point to unmet needs. The data was drawn from publications by Israeli government authorities and academic publications. In 2022, the prevalence of child and adolescent autism in Israel was approximately 1.13%, with a male-to-female ratio of 4:1, and an annual increase of 23%, particularly among young children. In Israel, the diagnosis of autism follows the DSM-5 guidelines and is conducted by a physician and a psychologist specializing in autism. Typically, diagnosis is at age 2. The autism intervention approaches prevalent in Israel are consistent with those that are globally accepted. Children with autism are entitled to special education services adapted to their needs and developmental levels. The legally established package of services for children with autism includes sessions with occupational therapists, speech-language pathologists (SLPs), physical therapists, psychologists, and social workers. Children and adults with autism are eligible for disability allowance along with support regarding residence, educational programs, and employment opportunities. Nonetheless, underdiagnosis and low accessibility to services are common in minority populations and rural areas. Furthermore, in recent years, services for autistic individuals have declined. This decline, particularly considering the ongoing rise in the prevalence of autism, pose significant challenges for Israeli government authorities in ensuring that autistic persons receive appropriate support.

Transmethylation and Oxidative Biomarkers in Children with Autism Spectrum Disorder: A Cross Sectional Study

We aimed to investigate the potential role of biomarkers of transmethylation, oxidative stress, and mitochondrial dysfunction in children with Autism Spectrum Disorder (ASD) by comparing them with that of typically developing children (TDC) controls. We also tried to correlate them with severity of autism, sensory issues, behavioural comorbidities and developmental quotients 119 with ASD and 52 age and sex matched typically developing children (TDC) controls were enrolled excluding those with chronic-illness or on any antioxidant therapy/multivitamins/anti-epileptic drugs. Median levels of biomarkers - serum homocysteine, cysteine, methionine, urine uric acid-to-creatinine ratio, arterial lactate, serum vitamin E, vitamin B12, folate, Nε-carboxymethyllysine, Nω- carboxymethylarginine (CMA), dityrosine and MTHFR C677T polymorphism were calculated. Children with ASD were further characterised using Childhood Autism Rating Scale-2, Childhood behavioural checklist, child sensory profile 2 caregiver questionnaire, Developmental Profile 3 for any correlation with the various biomarker levels. The median level of serum homocysteine in ASD group was 9 μmol/L(Range, 7- 16μmol/L), which was significantly higher than controls 7 μmol/L(Range, 4- 11μmol/L)(p=0.01). The prevalence of hyper-homocystinemia(>15μmol/L) was 13.4% in ASD as compared to 3.8% in controls with a significant difference(p=0.04). Dityrosine level was higher among ASD children when compared to TDC (9.8 vs 2.2 counts per second(cps), p<0.001). No significant correlation was found between prevalence of hyperhomocysteinemia and severity of autism/DQ/behavioural issues. No significant difference was found between the median levels of other biomarkers. Results support possible role of transmethylation defects and oxidative stress in ASD pathogenesis. Further studies are warranted for a better understanding of ASD pathogenesis.

Acute effects of exercise on gaze fixation and affective response inhibition in children with autism spectrum disorder: A randomized cross-over study

Children with autism spectrum disorder (ASD) show impairments in response inhibition, especially in socio-emotional contexts. A single aerobic exercise session has the potential to temporarily reduce such impairments as findings from neurotypical children support acute benefits of this exercise type for inhibitory control and emotion recognition. In children with ASD, we therefore aimed to investigate the effects of an aerobic exercise bout on response inhibition in an emotional Go/NoGo task and gaze fixation as possible mechanism underlying changes in performance. Using a cross-over design, 29 patients completed a 20-min aerobic exercise bout at moderate intensity on a cycling ergometer and a control condition in a randomized order. An emotional Go/NoGo task was administered before and after both experimental conditions. Eye-tracking was performed during the cognitive task to assess the duration of gaze fixation of eyes and mouth parts of faces expressing happy or sad emotions. The results support no beneficial effect of exercise on performance on the emotional Go/NoGo task. Instead, patients showed a greater decrease in accuracy on Go trials displaying happy faces in the exercise compared to the control condition. This change was associated with a more pronounced decrease in the fixation duration of the eyes for faces expressing either happy or sad emotions. In conclusion, while a single session of moderately intense aerobic exercise does not affect response inhibition, it temporarily aggravates ASD-specific deficits in the processing of and response to facial emotions.

Prevalence of Autism in Scandinavian Countries (Denmark, Norway, Sweden), and Nordic Countries (Finland, Iceland, the Faroe Islands, and Greenland)

Aim

This study aims to identify and describe prevalence rates for ASD in the Scandinavian countries (Denmark, Norway, Sweden), as well as the Nordic countries (Finland, Iceland, the Faroe Islands, and Greenland).

Methods

A systematic review was conducted following PRISMA (2009) guidelines and based on the two databases: APA PsycINFO and MEDLINE (PubMed).

Results

A total of 13 studies were included in the analyses. It was not possible to identify ASD prevalence studies for Greenland. However, for the remaining countries descriptive increases in ASD prevalence figures were observed. Increases were evident both in relation to age and birth cohort. Studies varied regarding which age group and cohort prevalence figures were reported. The most reported age group was the 7-12-year-olds. In this group, recent prevalence figures for Denmark ranged from 0.26% to 1.47%, in Norway 0.6%, in Sweden 0.23-0.68%, in Finland 0.22-0.86%, and in Iceland 2.40-3.13%. Iceland stood out in terms of higher prevalence figures compared to the other Scandinavian and Nordic countries. Two studies from the Faroe Islands reported ASD prevalence rates between 0.50% and 0.94% for 7-24-year-olds. These studies were based on nationwide figures, but not from national or official registers.

Discussion and conclusion

This study documented increasing prevalence of ASD in Scandinavian and Nordic countries. Several explanations of aspects that may contribute to the increases were discussed, eg, heightened awareness of ASD and earlier diagnosis. The importance of considering differences in data sources was discussed, with an emphasis on the importance of using national registries when available as this source is the most reliable and valid. The absence of prevalence figures for Greenland may be attributed to structural as well as cultural aspects, eg, two parallel systems assessing ASD, cultural taboos as well as lack of awareness of ASD. Suggestions or how to gain knowledge on ASD prevalence in Greenland is presented.

Validity of the Systemizer Profile Questionnaire: A New Tool to Identify Cognitive, Mentalizing, Sensory, Social, and Systemizing Abilities in Adults with Autism-Spectrum-Disorders With and Without Comorbid ADHD

PURPOSE

Systemizer Profile Questionnaire (SPQ), which has not been used before, investigates difficulties in mentalisation, sensory- and/or social sensitivity and social cognition (MSSSC) in subjects with Autism-Spectrum-Disorders (ASD) with and without Attention-Deficit-Hyperactivity-Disorder (ADHD). The aim of this study was to evaluate the reliability and validity of the SPQ domains, and to assess the predictive validity of the SPQ against the Ritvo Autism Asperger Diagnostic Scale (RAADS).

METHODS

Three-hundred-fifty-four study subjects with ICD-10 verified ASD confirmed by RAADS and 354 controls matched on age group and gender were recruited and evaluated systematically with SPQ, standardized questions about demographic and clinical data. Hypothesized SPQ subscales formed from 85 items were evaluated using confirmatory factor analysis (CFA). Resulting revised sub-scales were confirmed using item response theory (IRT) and the predictive validity of the SPQ scores was evaluated using RAADS scores above 64 as the standard.

RESULTS

Twenty-two of the original 85 items were removed, resulting in an instrument with 63 items across nine psychometrically valid domains. These domains had high sensitivity (range: 0.64 to 0.84), and high specificity (range: 0.73 to 0.90). Positive predictive values (range: 0.76 to 0.89) and negative predictive values (range: 0.69 to 0.90) were also high. For the total SPQ score the sensitivity was 0.95, the specificity was 0.87, the positive predictive value was 0.88 and the negative predictive value was 0.95.

CONCLUSION

SPQ domains are valid descriptions/profiles of MSSSC given that ASD is confirmed by RAADS, though irrelevant if not, as SPQ is not a diagnostic instrument.

Developing Knowledge of Autism in Majority World Countries: Examples of Bolivia and Paraguay

Bolivia and Paraguay are Majority World countries, which are defined as areas within which most of the world's population live, natural resources and landmass are located, but are often economically poor. Minority world countries, such as, the United States, have a smaller percentage of the world's population, but often a greater share of the world's wealth. Many Majority World countries, such as Bolivia and Paraguay, have not collected prevalence data on autism and assessments and interventions for persons are quite limited, if they are available at all. Persons with autism in Bolivia and Paraguay are at most underserved and the majority are unserved. This article reviews topological, demographic, and economic/political factors affecting the identification and provisions of services for autistic children and the current health and educational status for autistic persons in Bolivia and Paraguay. Descriptions of the efforts of outside consultants to assist parents and professional within those countries to gain information and develop assessment and intervention programs for autistic children are described. Attention is given to methodologies employed by United States consultants to ensure the implementation of culturally responsive practices. Consultants employed skilled dialogue when interviewing parents and professionals in Bolivia and Paraguay to understand their perspectives so as to guide content of trainings. The PRECEDE-PROCEED framework was employed to develop a culturally-responsive approach to assessment and intervention.