Hostname: page-component-cd9895bd7-dzt6s Total loading time: 0 Render date: 2024-12-22T18:45:28.436Z Has data issue: false hasContentIssue false
  • English
  • Français

Duration of untreated autism in rural America: emerging public health crisis

Published online by Cambridge University Press:  21 February 2022

Mayank Gupta Open the ORCID record for Mayank Gupta [Opens in a new window] ,
Nihit Gupta Open the ORCID record for Nihit Gupta [Opens in a new window]  and
Jeffrey Moll
Mayank Gupta*
Affiliation:
Clarion Psychiatric Center, Clarion, PA, USA
Nihit Gupta
Affiliation:
Reynolds Memorial Hospital, West Virginia University, Glen Dale, WV, USA
Jeffrey Moll
Affiliation:
Clarion Psychiatric Center, Clarion, PA, USA
*
*Author for correspondence: Mayank Gupta, MD Email: mayank6nov@gmail.com
Rights & Permissions [Opens in a new window]

Abstract

The rural areas have been at the receiving end amidst mental health disparity across the USA. There is a serious and concerning divide among ones with autism spectrum disorders (ASDs) living in underserved areas as compared to urban residents. With the higher than ever prevalence of ASD as per the recent reports of the Centers for Disease Control and Prevention; there is a need for a closer look at the prevailing issues. The trends are reflecting marked underdiagnosis, late diagnosis, lack of evidence-based diagnostic measures and interventions. These factors interplay in worsening the mental health crisis and there is an urgent need for corrective measures to address these highly modifiable problems.

Type
Editorial
Information
CNS Spectrums , Volume 28 , Issue 3 , June 2023 , pp. 271 - 274
Copyright
© The Author(s), 2022. Published by Cambridge University Press

Introduction

Despite many advances in the knowledge of autism spectrum disorder (ASD), newer evidence is beyond the reach of the rural populations. The data of the mental health crisis reflects the significant disparity in quality, access, and costs. The increase in suicide rates among adolescents,Reference Fontanella, Hiance-Steelesmith and Phillips1 the opioid crisis in adults are a few recent trends that have bought widespread attention to the rural mental health crisis.2

ASD could be diagnosed at the age of 12 to 14 months,Reference Turner-Brown, Baranek, Reznick, Watson and Crais3 and it is a highly stable diagnosis maintained at age 3.Reference Pierce, Gazestani and Bacon4 It takes 36 months after parental concerns to have a formal diagnosis.Reference Oswald, Haworth, Mackenzie and Willis5-Reference Glascoe7 Parental concerns are known to detect 70% to 80% of children with disabilities.Reference Mitroulaki, Serdari and Tripsianis8 The Autism and Developmental Disabilities Monitoring (ADDM) Network surveillance is critical to accurately measure epidemiology and has highlighted the variability in the prevalence. The average age of diagnosis is between 4 and 7 years,Reference Baio, Wiggins and Christensen9, Reference van’t Hof, Tisseur and van Berckelear-Onnes10 and the global mean average age is around 60.8 months.Reference Maenner11

In 2021, the Centers for Disease Control and Prevention (CDC) has changed the prevalence of ASD from 1 in 54 (1.9%) to 1 in 44 (2.3%) 8-year-old children.Reference Aylward, Gal-Szabo and Racial12 There are many serious implications of this revised prevalence, first, the likelihood of underdiagnoses in children with specific ethnicity,Reference Constantino, Abbacchi and Saulnier13 race,Reference McNally Keehn, Ciccarelli, Szczepaniak, Tomlin, Lock and Swigonski14 and living in the underserved areas.Reference Antezana, Scarpa, Valdespino, Albright and Richey15 Second, if the prevalence was high then what happened to the undiagnosed, and finally, what is the extent of rural disparities.Reference Pierce, Courchesne and Bacon16

The 2016 U.S. Preventive Services Task Force recommendations against universal screenings were criticizedReference Hosozawa, Sacker and Cable17 but given the newer data, is it a serious public health concern, it should be reconsidered? We appraise some critical determinants and their impact on the clinical practices in rural areas.

Duration of untreated autism

Late diagnosis of ASD is associated with a higher incidence of depression and self-harm in adolescents.Reference Bargiela, Steward and Mandy18 The ADDM reports the median age of ASD diagnosis among children under age 8 was lowest in the urban population of California, Maryland, and New Jersey with California having the lowest median age of 36 months. And longest in rural states of Minnesota (63 months), Arizona (58 months), and Wisconsin (56 months).Reference Aylward, Gal-Szabo and Racial12 These data also suggest a significant disparity between states with the highest prevalence like California (1:26) with the lowest in Missouri (1:60).Reference Aylward, Gal-Szabo and Racial12 The ADDM Network surveillance found the prevalence is similar among Caucasians, African Americans, and Hispanic nationally.Reference Aylward, Gal-Szabo and Racial12 However, these data also vary between states with some states ASD is more prevalent among the Caucasian population while others like Maryland and Minnesota where ASD was more prevalent in an African American population.Reference Aylward, Gal-Szabo and Racial12

Females

The delay in females is more pervasive given only recently there is more recognition of a distinct phenotypeReference Leedham, Thompson, Smith and Freeth19 and also symptomatology is been different from males.Reference Kaat, Shui and Ghods20 There have been recent efforts in modifying the Autism Diagnostic Observation Scale Second edition (ADOS-2) text to identify femalesReference Kentrou, de Veld, Mataw and Begeer21 but they continue to be underrepresented in the overall prevalence of ASD with a sex ratio of 4.2 in favor of males.Reference Aylward, Gal-Szabo and Racial12

Comorbidity

It is also been reported that ASD has many overlapping symptoms with ADHD.Reference Casanova, Frye, Gillberg and Casanova22 It is widely accepted that the presence of comorbidity not only challenges treatment but also has diagnostic implications.Reference Leader, Hogan and Chen23, Reference Randall, Egberts and Samtani24 Another study suggests many with ASD were diagnosed with ADHD and as a result, there was a significant delay in the diagnosis.Reference Casanova, Frye, Gillberg and Casanova22 Table 1.

Table 1. The Summary of Facts Related to the Delay in the Diagnosis of Autism in Rural Areas

Abbreviations: ASD, autism spectrum disorder; CDC, Centers for Disease Control and Prevention.

The myths and utilities of testing

Diagnostic tools Autism Diagnostic Observation Scale Second edition, Autism Diagnostic Interview-Revised, Childhood Autism Rating Scale (ADOS-2, ADI, CARS) are recommended to be part of the multidisciplinary assessment in preschoolersReference Kamp-Becker, Albertowski and Becker25 and not as stand-alone measures. Despite improved accuracy of the gold standard tools like ADOS-2Reference Maddox, Brodkin and Calkins26, they may not identify all cases of ASD.Reference Miller, Adam and Aradhya27 There are concerns about the cost-effectiveness of ADOS-2 and the need for extensive training requirements.Reference Maddox, Brodkin and Calkins26 On comparative analysis of sensitivity, specificity, and the positive predictive value (PPV) of the diagnostic tools, ADOS was more sensitive but all three of them had the same specificity.Reference Kamp-Becker, Albertowski and Becker25

Genetic testing

Chromosomal microarray analysis (CMA) has been recommended as the standard of care for the initial evaluation of children with developmental disabilities and/or ASDs.Reference Kreiman and Boles28 The emergence of low-cost whole-exome sequence (WES) and whole-genome sequence (WGS), which are preferred over CMA.Reference Harris, Sideridis, Barbaresi and Harstad29 A study has found 12% with ASD have pathologic findings on the genetic testingReference Mehta30 and as per AACAP, it could be as high as one-third in suspected cases.Reference Guthrie, Wallis and Bennett31 Genetic testing is rarely done in rural areas although there is no data to support it.

Reasons for late diagnosis in the rural US

Two recent studies found the sensitivity and PPV of the most commonly used screening tool the Modified Checklist for Autism in Toddlers (MCHAT) was in the range of 33.1% to 38.8%, and 14.6% to 17.8%, respectively.Reference Carbone, Campbell and Wilkes32, Reference Wallis and Guthrie33 Both studies have called for a paradigm shift in screenings given current tools’ has poor sensitivity and false negatives.Reference Davidovitch, Levit-Binnun, Golan and Manning-Courtney34, Reference Hosozawa, Sacker, Mandy, Midouhas, Flouri and Cable35

A British population-based cohort found those living in poverty and with higher intelligence are likely to miss out on the initial screenings.Reference Zuckerman, Broder-Fingert and Sheldrick36 Therefore, testing preschoolers from low-income families and minorities may identify these children.Reference Kuhn, Levinson and Udhnani37 Multilingual staff may increase accuracy given MCHAT has a poor PPV in ethnic minority.Reference Ozonoff, Young and Brian38 There is presence of a distinct subtle phenotype that lacks symptoms at early stages and therefore detection before age 4 is difficult due to the heterogeneous nature of ASD.Reference Ozonoff, Young and Landa39 These studies emphasize the value of longitudinal follow-up beyond 36 months.Reference Rice, Rosanoff and Dawson40

There is a clear divide between the prevalence of ASD in states with urban populations (California and New Jersey) as compared to that with the rural population (Missouri and Wisconsin).Reference Aylward, Gal-Szabo and Racial12 These differences in the prevalence could be attributed to the changes in the diagnostic criteria and higher health care literacy in urban areas.Reference Palmer, Blanchard, Jean and Mandell41, Reference Mandell and Palmer42 The state public health awareness programs also contribute to improving awareness among parents.43

Evidence-based interventions which work is not available to many who needs the most

The higher prevalence could also be linked to the higher density of mental health workforceReference Chasson, Harris and Neely44 with Maryland being the only outlier.Reference Aylward, Gal-Szabo and Racial12 The services are clustered around urban pockets with higher per capita income. Also, the average cost for Applied Behavioral Analysis is $60,000 per year which totals to $240,000 for 4 years of treatment.Reference Siu and Bibbins-Domingo45

Discussion

Currently, MCHAT is recommended at 16 months of age in suspected cases and universal screening is not recommended.Reference Kim, Joseph and Frazier46 As the burden of missed or late diagnosis of ASD continues to mount, the scientific basis for controversial population-based universal screening growing. There is also a need for a screening tool that is highly specific, sensitive, and with a good PPV given MCHAT has both poor specificity and sensitivity.Reference Albores-Gallo, Roldán-Ceballos and Villarreal-Valdes47 Additionally, translated versions of MCHAT perform suboptimally.Reference Nukeshtayeva, Lubchenko, Omarkulov and DeLellis48, Reference Smith, Malcolm-Smith and de Vries49 Special attention is required for the underrepresented minority population. There is a need to modify questions in the ADOS-2 based upon the cultural context to reduce the diagnostics bias.Reference Magaña and Smith50 Even the Spanish-translated version is less accurate compared to English; despite Spanish being the second most spoken language in the US.Reference Horlin, Falkmer, Parsons, Albrecht and Falkmer51 Cost-effective, readily accessible tools assist in early diagnosis and the access to interventions may not only improve the long-term outcomes but also reduce the overall cost. The multidisciplinary approaches for diagnostics and treatments are expensive to set up and continue to remain a barrier in underserved areas.Reference Barrett, Mosweu and Jones52, Reference Abbas, Garberson, Liu-Mayo, Glover and Wall53

The emerging evidence of artificial intelligence-based platforms is encouraging since it has the potential to address diagnostics issues and are also cost-effective.Reference Kleberg, Högström, Nord, Bölte, Serlachius and Falck-Ytter54 Many diagnostic instruments that are underutilized, training staff to use ADI-R, ADOS-2, CARS-3, GADS may be highly prudent in rural areas with limited resources. The gold standard diagnostic tool ADOS is highly sensitive but lacks specificity.Reference Kamp-Becker, Albertowski and Becker25 This is observed in ones with fewer symptoms of ASD and when associated with comorbid ADHD or social anxiety disorder.Reference Kleberg, Högström, Nord, Bölte, Serlachius and Falck-Ytter55 Therefore, in many with fewer symptoms of ASD and associated comorbidities, diagnosis is more difficult.Reference Leader, Hogan and Chen23, Reference Randall, Egberts and Samtani24 The adults with high functioning ASD may compensate for their deficits, and never meet the criteria for autism even with ADOS-2.Reference Adamou, Jones and Wetherhill56

Finally, significant advocacy is needed for the rural low-income populations living in the underserved areas with a low incidence of ASD.

Author Contributions

Conceptualization: M.G., N.G., J.M.; Data curation: M.G., N.G.; Formal analysis: J.M.; Writing—original draft: M.G., N.G.; Writing—review and editing: N.G.

Disclosures

The authors declare none.

References

Fontanella, CA, Hiance-Steelesmith, DL, Phillips, GS, et al. Widening rural-urban disparities in youth suicides, United States, 1996-2010. JAMA Pediatr. 2015;169(5):466–473.CrossRefGoogle ScholarPubMed
Center for Disease Control. CDC reports rising rates of drug overdose deaths in rural areas; 2017. https://www.cdc.gov/media/releases/2017/p1019-rural-overdose-deaths.html. Accessed December 21, 2021.Google Scholar
Turner-Brown, LM, Baranek, GT, Reznick, JS, Watson, LR, Crais, ER. The First Year Inventory: a longitudinal follow-up of 12-month-old to 3-year-old children. Autism Int J Res Pract. 2013;17(5):527–540.CrossRefGoogle ScholarPubMed
Pierce, K, Gazestani, VH, Bacon, E, et al. Evaluation of the diagnostic stability of the early autism spectrum disorder phenotype in the general population starting at 12 months. JAMA Pediatr. 2019;173(6):578–587.CrossRefGoogle ScholarPubMed
Oswald, DP, Haworth, SM, Mackenzie, BK, Willis, JH. Parental report of the diagnostic process and outcome: ASD compared with other developmental disabilities. Focus Autism Dev Disabil. 2017;32(2):152–160.CrossRefGoogle Scholar
Am, D, Ds, M. Explaining differences in age at autism spectrum disorder diagnosis: a critical review. Autism Int J Res Pract. 2014;18(5):583–597. doi:10.1177/1362361313480277.Google Scholar
Gordon-Lipkin, E, Foster, J, Peacock, G. Whittling down the wait time: exploring models to minimize the delay from initial concern to diagnosis and treatment of autism spectrum disorder. Pediatr Clin North Am. 2016;63(5):851–859.10.1016/j.pcl.2016.06.007CrossRefGoogle ScholarPubMed
Glascoe, FP. Evidence-based approach to developmental and behavioural surveillance using parents’ concerns. Child Care Health Dev. 2000;26(2):137–149.10.1046/j.1365-2214.2000.00173.xCrossRefGoogle ScholarPubMed
Mitroulaki, S, Serdari, A, Tripsianis, G, et al. First alarm and time of diagnosis in autism spectrum disorders. Compr Child Adolesc Nurs. 2020;22:1–17.Google Scholar
Baio, J, Wiggins, L, Christensen, DL, et al. Prevalence of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 sites, United States, 2014. MMWR Surveill Summ. 2018;67(6):1–23.CrossRefGoogle Scholar
van’t Hof, M, Tisseur, C, van Berckelear-Onnes, I, et al. Age at autism spectrum disorder diagnosis: a systematic review and meta-analysis from 2012 to 2019. Autism Int J Res Pract. 2021;25(4):862–873.CrossRefGoogle ScholarPubMed
Maenner, MJ. Prevalence and characteristics of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 sites, United States, 2018. MMWR Surveill Summ. 2021;70:1–16.CrossRefGoogle Scholar
Aylward, BS, Gal-Szabo, DE, Racial, TS. Ethnic, and sociodemographic disparities in diagnosis of children with autism spectrum disorder. J Dev Behav Pediatr. 2021;42(8):682–689.10.1097/DBP.0000000000000996CrossRefGoogle ScholarPubMed
Constantino, JN, Abbacchi, AM, Saulnier, C, et al. Timing of the diagnosis of autism in African American Children. Pediatrics. 2020;146(3):e20193629. doi:10.1542/peds.2019-3629.CrossRefGoogle ScholarPubMed
McNally Keehn, R, Ciccarelli, M, Szczepaniak, D, Tomlin, A, Lock, T, Swigonski, N. A statewide tiered system for screening and diagnosis of autism spectrum disorder. Pediatrics. 2020;146(2):e20193876. doi:10.1542/peds.2019-3876.CrossRefGoogle ScholarPubMed
Antezana, L, Scarpa, A, Valdespino, A, Albright, J, Richey, JA. Rural trends in diagnosis and services for autism spectrum disorder. Front Psychol. 2017;8:590.10.3389/fpsyg.2017.00590CrossRefGoogle ScholarPubMed
Pierce, K, Courchesne, E, Bacon, E. To screen or not to screen for ASD universally is not the question: why the task force got it wrong. J Pediatr. 2016;176:182–194.CrossRefGoogle Scholar
Hosozawa, M, Sacker, A, Cable, N. Timing of diagnosis, depression and self-harm in adolescents with autism spectrum disorder. Autism. 2021;25(1):70–78.10.1177/1362361320945540CrossRefGoogle ScholarPubMed
Bargiela, S, Steward, R, Mandy, W. The experiences of late-diagnosed women with autism spectrum conditions: an investigation of the female autism phenotype. J Autism Dev Disord. 2016;46(10):3281–3294.CrossRefGoogle ScholarPubMed
Leedham, A, Thompson, AR, Smith, R, Freeth, M. “I was exhausted trying to figure it out”: the experiences of females receiving an autism diagnosis in middle to late adulthood. Autism Int J Res Pract. 2020;24(1):135–146.CrossRefGoogle ScholarPubMed
Kaat, AJ, Shui, AM, Ghods, SS, et al. Sex differences in scores on standardized measures of autism symptoms: a multisite integrative data analysis. J Child Psychol Psychiatry. 2021;62(1):97–106.CrossRefGoogle ScholarPubMed
Kentrou, V, de Veld, DM, Mataw, KJ, Begeer, S. Delayed autism spectrum disorder recognition in children and adolescents previously diagnosed with attention-deficit/hyperactivity disorder. Autism Int J Res Pract. 2019;23(4):1065–1072.CrossRefGoogle ScholarPubMed
Casanova, MF, Frye, RE, Gillberg, C, Casanova, EL. Editorial: comorbidity and autism spectrum disorder. Front Psychiatry. 2020;11:617395.10.3389/fpsyt.2020.617395CrossRefGoogle ScholarPubMed
Leader, G, Hogan, A, Chen, JL, et al. Age of autism spectrum disorder diagnosis and comorbidity in children and adolescents with autism spectrum disorder. Dev Neurorehabil. 2022;25(1):29–37.CrossRefGoogle ScholarPubMed
Randall, M, Egberts, KJ, Samtani, A, et al. Diagnostic tests for autism spectrum disorder (ASD) in preschool children. Cochrane Database Syst Rev. 2018;7(7):CD009044.Google ScholarPubMed
Kamp-Becker, I, Albertowski, K, Becker, J, et al. Diagnostic accuracy of the ADOS and ADOS-2 in clinical practice. Eur Child Adolesc Psychiatry. 2018;27(9):1193–1207.CrossRefGoogle ScholarPubMed
Maddox, BB, Brodkin, ES, Calkins, ME, et al. The accuracy of the ADOS-2 in identifying autism among adults with complex psychiatric conditions. J Autism Dev Disord. 2017;47(9):2703–2709.CrossRefGoogle ScholarPubMed
Miller, DT, Adam, MP, Aradhya, S, et al. Consensus statement: chromosomal microarray is a first-tier clinical diagnostic test for individuals with developmental disabilities or congenital anomalies. Am J Hum Genet. 2010;86(5):749–764.CrossRefGoogle ScholarPubMed
Kreiman, BL, Boles, RG. State of the art of genetic testing for patients with autism: a practical guide for clinicians. Semin Pediatr Neurol. 2020;34:100804.CrossRefGoogle ScholarPubMed
Harris, HK, Sideridis, GD, Barbaresi, WJ, Harstad, E. Pathogenic yield of genetic testing in autism spectrum disorder. Pediatrics. 2020;146(4):e20193211.CrossRefGoogle ScholarPubMed
Mehta, SQ. 5.1 the use of diagnostic genetic testing in autism and other neurodevelopmental disorders. J Am Acad Child Adolesc Psychiatry. 2017;56(10):S8.CrossRefGoogle Scholar
Guthrie, W, Wallis, K, Bennett, A, et al. Accuracy of autism screening in a large pediatric network. Pediatrics. 2019;144(4):e20183963.CrossRefGoogle Scholar
Carbone, PS, Campbell, K, Wilkes, J, et al. Primary care autism screening and later autism diagnosis. Pediatrics. 2020;146(2):e20192314.CrossRefGoogle ScholarPubMed
Wallis, KE, Guthrie, W. Identifying autism spectrum disorder in real-world health care settings. Pediatrics. 2020;146(2):e20201467.CrossRefGoogle ScholarPubMed
Davidovitch, M, Levit-Binnun, N, Golan, D, Manning-Courtney, P. Late diagnosis of autism spectrum disorder after initial negative assessment by a multidisciplinary team. J Dev Behav Pediatr JDBP. 2015;36(4):227–234.CrossRefGoogle ScholarPubMed
Hosozawa, M, Sacker, A, Mandy, W, Midouhas, E, Flouri, E, Cable, N. Determinants of an autism spectrum disorder diagnosis in childhood and adolescence: evidence from the UK Millennium Cohort Study. Autism. 2020;24(6):1557–1565.CrossRefGoogle ScholarPubMed
Zuckerman, KE, Broder-Fingert, S, Sheldrick, RC. To reduce the average age of autism diagnosis, screen preschoolers in primary care. Autism Int J Res Pract. 2021;25(2):593–596.CrossRefGoogle ScholarPubMed
Kuhn, J, Levinson, J, Udhnani, MD, et al. What happens after a positive primary care autism screen among historically underserved families? predictors of evaluation and autism diagnosis. J Dev Behav Pediatr JDBP. 2021;42(7):515–523.CrossRefGoogle ScholarPubMed
Ozonoff, S, Young, GS, Brian, J, et al. Diagnosis of autism spectrum disorder after age 5 in children evaluated longitudinally since infancy. J Am Acad Child Adolesc Psychiatry. 2018;57(11):849–857.e2.CrossRefGoogle ScholarPubMed
Ozonoff, S, Young, GS, Landa, RJ, et al. Diagnostic stability in young children at risk for autism spectrum disorder: a baby siblings research consortium study. J Child Psychol Psychiatry. 2015;56(9):988–998.CrossRefGoogle ScholarPubMed
Rice, CE, Rosanoff, M, Dawson, G, et al. Evaluating changes in the prevalence of the autism spectrum disorders (ASDs). Public Health Rev. 2012;34(2):1–22.CrossRefGoogle ScholarPubMed
Palmer, RF, Blanchard, S, Jean, CR, Mandell, DS. School district resources and identification of children with autistic disorder. Am J Public Health. 2005;95(1):125–130.CrossRefGoogle ScholarPubMed
Mandell, DS, Palmer, R. Differences among states in the identification of autistic spectrum disorders. Arch Pediatr Adolesc Med. 2005;159(3):266–269.CrossRefGoogle ScholarPubMed
Workforce Maps by State. https://www.aacap.org/aacap/Advocacy/Federal_and_State_Initiatives/Workforce_Maps/Home.aspx. Published January 18, 2022. Accessed January 18, 2022.Google Scholar
Chasson, GS, Harris, GE, Neely, WJ. Cost comparison of early intensive behavioral intervention and special education for children with autism. J Child Fam Stud. 2007;16(3):401–413.CrossRefGoogle Scholar
Siu, AL, US Preventive Services Task Force (USPSTF), Bibbins-Domingo, K, et al. Screening for autism spectrum disorder in young children: US preventive services task force recommendation statement. JAMA. 2016;315(7):691–696.CrossRefGoogle ScholarPubMed
Kim, SH, Joseph, RM, Frazier, JA, et al. Predictive validity of the modified checklist for autism in toddlers (M-CHAT) born very preterm. J Pediatr. 2016;178:101–107.e2.CrossRefGoogle ScholarPubMed
Albores-Gallo, L, Roldán-Ceballos, O, Villarreal-Valdes, G, et al. M-CHAT Mexican version validity and reliability and some cultural considerations. ISRN Neurol. 2012;2012:408694.CrossRefGoogle ScholarPubMed
Nukeshtayeva, K, Lubchenko, M, Omarkulov, B, DeLellis, N. Validation non-English version of modified checklist for autism in toddlers-revised with follow-up. J Clin Med Kazakhstan. 2021;18(4):4–11.CrossRefGoogle Scholar
Smith, L, Malcolm-Smith, S, de Vries, PJ. Translation and cultural appropriateness of the autism diagnostic observation schedule-2 in Afrikaans. Autism Int J Res Pract. 2017;21(5):552–563.CrossRefGoogle ScholarPubMed
Magaña, S, Smith, LE. The use of the autism diagnostic interview-revised with a Latino population of adolescents and adults with autism. J Autism Dev Disord. 2013;43(5):1098–1105.CrossRefGoogle ScholarPubMed
Horlin, C, Falkmer, M, Parsons, R, Albrecht, MA, Falkmer, T. The cost of autism spectrum disorders. PLoS One. 2014;9(9):e106552.CrossRefGoogle ScholarPubMed
Barrett, B, Mosweu, I, Jones, CR, et al. Comparing service use and costs among adolescents with autism spectrum disorders, special needs and typical development. Autism Int J Res Pract. 2015;19(5):562–569.CrossRefGoogle ScholarPubMed
Abbas, H, Garberson, F, Liu-Mayo, S, Glover, E, Wall, DP. Multi-modular AI approach to streamline autism diagnosis in young children. Sci Rep. 2020;10:5014.CrossRefGoogle ScholarPubMed
Kleberg, JL, Högström, J, Nord, M, Bölte, S, Serlachius, E, Falck-Ytter, T. Autistic traits and symptoms of social anxiety are differentially related to attention to others’ eyes in social anxiety disorder. J Autism Dev Disord. 2017;47(12):3814–3821.CrossRefGoogle ScholarPubMed
Adamou, M, Jones, SL, Wetherhill, S. Predicting diagnostic outcome in adult autism spectrum disorder using the autism diagnostic observation schedule, second edition. BMC Psychiatry. 2021;21(1):24.CrossRefGoogle ScholarPubMed
Figure 0

Table 1. The Summary of Facts Related to the Delay in the Diagnosis of Autism in Rural Areas