PROSPERO

International prospective register of systematic reviews

Prevalence of autism spectrum disorder in low and middle-income countries: a systematic

review and meta-analysis
Ashmita Chaulagain, Mami Fukaya

Citation
Ashmita Chaulagain, Mami Fukaya. Prevalence of autism spectrum disorder in low and middle-
income countries: a systematic review and meta-analysis. PROSPERO 2020 CRD42020147899
Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020147899

Review question
What is the prevalence of Autism Spectrum Disorder (ASD) in low and lower-middle-income countries?

Searches

We will search the following electronic bibliographic databases: MEDLINE, Embase, Web of Science,
PsycINFO. The search strategies, adopted for the different database, will include a combination of
thesaurus- (where available) and free-text terms to identify studies on the prevalence of Autism Spectrum
Disorder in low and lower-middle-income countries (according to World Bank–definition). The reference lists
of the eligible studies and review articles will also be screened to identify potentially relevant studies not
indexed in the databases.

The searches will be limited to 1980 onwards, updating the literature published since DSM-III first appeared
in 1980.

No language restrictions will be applied.

Types of study to be included

Inclusion:
Study design: Observational studies (Cross-sectional studies and Cohort );
Study area: World bank defined low and lower-middle-income countries;

Studies including participants of all ages (children, adolescents, and adults) and gender (males and
females).

Exclusion:

Papers published before 1980;

Hospital-based studies;

Studies conducted in upper-middle and high-income countries.

Condition or domain being studied

Autism spectrum disorder (ASD), is one of the most common neurodevelopmental disorders of childhood
characterized by some degree of impaired social behavior, communication and language, and restricted
interest that are both unique and repetitive. While the full range of ASD etiology remains unknown, available
scientific evidence suggests that both genetic and environmental factors make a child more likely to develop

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ASD.

Participants/population
Participants/population: We will include studies involving children, adolescents and adult population
(regardless of age or gender) with autism spectrum disorder

Intervention(s), exposure(s)
Not applicable

Comparator(s)/control
Not applicable

Main outcome(s)
The primary outcome will be the prevalence of ASD.
* Measures of effect
Not applicable

Additional outcome(s)
Not applicable
* Measures of effect
Not applicable

Data extraction (selection and coding)

Two reviewers will independently screen all articles identified from the literature search. Firstly, titles and
abstracts of articles returned from initial searches will be screened based on the eligibility criteria outlined
above. Secondly, full texts will be examined in detail and screened for eligibility. Additionally, references of all
considered articles will be hand-searched to identify any relevant report missed in the search strategy. The
third reviewer will resolve any discrepancies in the two reviewers opinions at any stage.

A data extraction form will be designed and used to extract equivalent information from each study report.
Information of interest will include the following: Study characteristics (e.g. study design, year of publication,
journal, sample size, setting: community, school ; geographical area; and other fields to capture data relevant
to the assessment of study methodological quality); Participant characteristics (e.g. population sampled, age
and gender); and Outcome results: definitions and assessment tools (e.g. DSM III or DSM IV or DSM V or
ICD 9 or ICD10 criteria), data collection method, prevalence estimates, and any prevalence estimates
stratified by age, gender, severity, or location. If required authors of primary publications will be contacted for
data clarifications or missing outcome data.

Risk of bias (quality) assessment

Critical appraisal checklist proposed in the Joanna Briggs Institute (JBI) systematic review methods manual
will be used to assess the risk of bias of primary observational studies that provide prevalence of ASD. This
checklist considers sample representativeness, recruitment appropriateness, sample size, description of
subjects and setting, coverage of data analysis, ascertainment and measurement of the condition,
thoroughness of reporting statistical analysis, and identification and accountability of potential confounding
factors/subgroups. Studies will be scored to be at low risk of bias (?7 points), moderate risk of bias (4-6
points) or high risk of bias (<4 points). The risk of bias for each observational study will be independently
assessed by two reviewers. Any discrepancy in the scores will be resolved by contacting the third reviewer.

Strategy for data synthesis

The data from each paper will be used to build evidence tables of an overall description of the included
studies. Crude prevalence estimates (number of cases/sample size) will be presented along with 95%
confidence intervals.

We will use prevalence data points from primary observational studies to perform random-effects meta-
analyses. We will estimate the pooled-prevalence and its 95% confidence interval using the random-effects
model with logit transformation and back transformation. Prevalence estimates will be expressed as cases

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per 10, 000 people.

Heterogeneity will be assessed by using I² statistic and Cochrane Q test.

Analysis of subgroups or subsets

If feasible, potential sources of heterogeneity will be investigated further by subgroup or meta-regression
analyses according to baseline characteristics and methodological covariates. We plan to conduct analyses
by gender (male vs female), age (e.g. children vs adolescent vs adult, mid-point of age range as continuous
variable), setting (e.g. community vs school ), sample size (e.g. <1000, 1000-5000 or >5000 participants),
decade of publication (e.g. 1980, 1990, 2000 or 2010), severity (e.g. mild, moderate or severe), World Health
Organization geographical region (South-East Asia Region, African Region, Region of the Americas,
European Region, Eastern Mediterranean Region, and Western Pacific Region ), study quality (e.g.
low/moderate vs high-risk of bias).

Contact details for further information

Ashmita Chaulagain
aol.ashmita@gmail.com

Organisational affiliation of the review

Regional Center for Child and Adolescent Mental Health and Child Welfare, Norwegian University of Science
and Technology
https://www.ntnu.no/rkbu

Review team members and their organisational affiliations

Ms Ashmita Chaulagain. Norwegian University of Science and Technology
Ms Mami Fukaya. Nagoya University

Collaborators
Professor Norbert Skokauskas. Norwegian University of Science and Technology
Professor Bennett L. Leventhal. University of California San Francisco
Dr Sindre Andre Pedersen. Norwegian University of Science and Technology

Type and method of review

Epidemiologic, Meta-analysis, Systematic review

Anticipated or actual start date

24 September 2019

Anticipated completion date

11 March 2020

Funding sources/sponsors
Trondheim and Nagoya Partnership Project

Conflicts of interest
Language
English

Country
Japan, Norway, United States of America

Stage of review
Review Ongoing

Subject index terms status

Subject indexing assigned by CRD

Subject index terms

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International prospective register of systematic reviews

Autism Spectrum Disorder; Developing Countries; Humans; Income; Prevalence

Date of registration in PROSPERO

02 March 2020

Date of first submission

17 September 2019

Stage of review at time of this submission

The review has not started

Stage Started Completed

Preliminary searches No No

Piloting of the study selection process No No

Formal screening of search results against eligibility criteria No No

Data extraction No No

Risk of bias (quality) assessment No No

Data analysis No No

The record owner confirms that the information they have supplied for this submission is accurate and
complete and they understand that deliberate provision of inaccurate information or omission of data may be
construed as scientific misconduct.

The record owner confirms that they will update the status of the review when it is completed and will add
publication details in due course.

Versions
02 March 2020

PROSPERO
This information has been provided by the named contact for this review. CRD has accepted this information in good
faith and registered the review in PROSPERO. The registrant confirms that the information supplied for this submission
is accurate and complete. CRD bears no responsibility or liability for the content of this registration record, any
associated files or external websites.

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