1. Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental disorder with onset in early childhood. A diagnosis of ASD requires the presence of impairment in two major domains: communication and social interaction, and restricted or repetitive patterns of behavior [
1]. ASD is considered multifactorial in origin where multiple genetic and epigenetic factors may contribute to the etiology [
2]. Research on ASD is relatively limited in developing countries, including Saudi Arabia, and thus most of the current clinical practices in Saudi Arabia are based on conclusions from studies conducted in Western developed countries [
3]. Although a marked growth in local research started to emerge in 2008, there is much that still has to be investigated. For instance, the prevalence of ASD in Saudi Arabia has not yet been accurately determined. One study stated that 42,500 cases were diagnosed with autism in 2002 [
4]. A more recent systematic review showed that the prevalence of ASD in Arabian Gulf countries, including Saudi Arabia, ranged from 1.4 to 29 per 10,000 population [
5]. This is, in fact, lower than the prevalence rate measured by studies conducted in developed countries (39–77 per 10,000). This does not necessarily mean that it is less prevalent in Saudi Arabia, as the discrepancy could be explained by methodological flaws, the limited capacity to diagnose ASD, and lower level of awareness of ASD among parents that reduces the likelihood of recognizing symptoms and consequent attempts to access care [
6]. A cross-sectional study involving 205 individuals with ASD showed that the ratio between males to female in that sample was 4.9:1. Psychiatric comorbidities were found in 65% of the patients. Among these comorbidities, attention deficit hyperactivity disorder (ADHD) was the most prevalent (53%), followed by intellectual disability (8%), then epilepsy and cerebral palsy (2% for each) [
7].
In Saudi Arabia, there is a considerable gap between the needs of individuals diagnosed with ASD and the currently available services. Although Saudi Arabia is a large country, most of the services are localized in its largest cities (i.e., Riyadh, Jeddah, or Dammam) [
7]. Furthermore, the provided services tend not to meet the satisfaction of families. In Saudi, a study that used a scale of excellent–good–acceptable–bad to evaluate publicly provided services for ASD showed that about 75% of the families scored them as acceptable or bad [
7]. Attesting to difficulties in accessing services in Saudi Arabia, Khan et al., in a recent cross-sectional study published in 2020, found that only 31% of children on the autism spectrum could access nearby autism centers, and 72% have no access to private schools for ASD in their area [
8]. The areas that are targeted through early intervention are language, play skills and social participation, activities of daily living (ADLs), and challenging behaviors [
9]. Moreover, pharmacological management can be initiated to target specific symptoms related to ASD, such as irritability, hyperactivity, aggression, aberrant social behavior, repetitive behavior, inattention, and insomnia. However, all medications might cause side effects that need to be monitored by a professional, so it should be prescribed by either a neurologist or a psychiatrist [
10]. In one study conducted in Saudi Arabia, almost half of the children on the autism spectrum were prescribed psychotropic medications mainly for behavioral management and risperidone was the most prescribed medication [
11].
The lack of governmental and institutional support for a child on the autism spectrum places a significant burden on parents, which might affect the quality of life for other siblings. It has been shown that almost 88.5% of parents of children on the autism spectrum in Saudi Arabia experience significant distress. The challenges and unmet needs of children on the autism spectrum resulting from lack of access to needed resources resulted in negative impacts on social and financial aspects of their lives, their family relationships, and the quality of life of the siblings of the children on the autism spectrum [
11]. In another cross-sectional study that involved 61 families of individuals diagnosed with ASD, 37% of the families felt embarrassed for having children on the autism spectrum, while almost 64% were bothered by the way that others in the community dealt with them [
6].
Currently, several authorities are involved in the journey of care, education, and empowerment for individuals diagnosed with ASD and others with other developmental disabilities. The initial screening (i.e., especially at a young age) and diagnostic services are carried out by specialized and trained healthcare professionals (i.e., general pediatricians, psychiatrists, child psychologists, developmental-behavioral or neurodevelopmental pediatricians, pediatric neurologists, or child psychiatrists) working in entities affiliated with the Ministry of Health (MoH) or accredited by public authorizing entities, such as Saudi Health Council (SHC), Saudi Commission for Health Specialties (SCFHS), and Saudi Central Board of Accreditation of Healthcare Institutions (CBAHI). This discrepancy in carrying out such services with different capacities might be attributed to the lack of clear guidance, shortage of specialized professionals, and availability of validated tools. Therefore, there have been calls to develop a nation-based policy to mitigate the lack of services for children on the autism spectrum [
12].
For post-diagnostic services, rehabilitation services are overseen by three entities: the MoH, the Ministry of Education (MoE), and the Ministry of Human Resources and Social Development (MHRSD), where services are provided through governmental (free-of-charge) providers or private (pay-for-services or covered by health insurance) ones (e.g., hospitals, schools, special needs centers, and specialized clinics). Despite some significant and successful initiatives to enhance accessibility and improve the quality of services, more need to be achieved in this regard [
13]. While MHRSD is overseeing and subsidizing intervention services that private centers provide to children who are not in school because they are younger than six years old or are severely impacted (IQ > 50), MoE serves students on the autism spectrum that do not have severe intellectual disability and have effective verbal communication in their public school systems, including some institutions that are designated for students with disabilities, special-needs classrooms, or mainstreamed (inclusion) classrooms along with their typical peers.
Intervention and special education services may vary from one center to another. Generally, the number of intervention hours received and its structure (group-format vs. individualized-format) varies mainly based on the limited service slots, ranging from 20 h/week to only a few. However, about 80% of families of individuals on the autism spectrum accessing early intervention services pay for them out-of-pocket and almost 92% of families reported an excessive financial burden related to the management of the needs of their children on the autism spectrum [
6]. As such, the status of services in Saudi Arabia might require a thorough review of the needs of individuals on the autism spectrum and their families and concerted efforts to attempt to meet them. To do so, there is a national need for expert consensus on appropriate standards for the assessment and management of children on the autism spectrum. This became possible after the Prince Mohammed Bin Salman Program for Autism and Developmental Disorders was established in 2018, which took this role to help to address those gaps in practice and funded this project to pave the way for more standardized care.
2. Materials and Methods
2.1. Team of Experts
The methodological approach utilized was based on a formal voting technique that included the review of the available scientific evidence and the involvement of ASD clinical experts to develop consensus-based recommendations on screening, assessment, and interventions for ASD in children under 16 years of age.
The expert consensus development process was conducted between 12/2018 and 09/2020 by a multidisciplinary expert clinical panel and a guideline development group (GDG) of five physicians (three child psychiatrists, a pediatric neurologist, and an adult neurologist) and ten doctoral level experts from relevant specialties (two clinical psychologists, two behavioral therapists, two speech and language pathologists, two occupational therapists, and two special education experts) from different healthcare-providing sectors that contribute to the healthcare provision for individuals diagnosed with ASD.
2.2. Guideline Development and Process
The process consisted of five steps: (i) literature review of the existing international guidelines; (ii) formulation of subgroups divided by clinical specialty to be assigned a relevant section of ASD management; (iii) each subgroup developed an initial draft of recommendations relevant to their specialty; (iv) review and discussion of the first draft from each subgroup with the larger group for integration, continuity of care, and finalization; and (v) writing up the final draft as a comprehensive clinical practice guideline (CPG) adapted to suit the Saudi Arabian culture and current healthcare system and having it vetted by a quality and patient safety team.
In the first step, a literature review was conducted to identify published evidence and practice guidelines relevant to the screening, diagnosis, intervention, and management of children with ASD. In the second and third steps, based on the results of the literature review and opinions of the assigned specialized subgroups, an initial draft of their specific recommendations was prepared by each of the clinical specialties. In the fourth step, each of the initial drafts was presented to the larger group to adjust, when necessary, multidisciplinarity and integration of care of children with ASD and to eliminate redundancies. In the final step, the final draft of the CPG’s recommendations was reviewed and approved using the Continuous Quality Improvement and Patient Safety Team (CQIPST) at Prince Sultan Military Medical City (PSMMC). The values and preferences of the child, parents, and caregivers as relevant to the Saudi Arabian context were considered during the finalization of the recommendations.
Overall, the GDG and its subgroups met on a regular basis for over 21 months, conducting 45 sessions; all were face-to-face meetings, except for the last two that were conducted online in compliance with precautionary measures related to the COVID-19 pandemic. The chair of the GDG was responsible to facilitate the discussions required to address and resolve any disagreements during these meetings for each recommendation statement by using formal voting.
A set of CPG implementation tools was incorporated in the finalized CPG document to facilitate future implementability. These tools included: (i) a method for the identification of the most responsible physician, (ii) a list of minimum standard qualifications for each category of healthcare providers that contributes to the healthcare provision, (iii) providers’ clinical documentation sheets, and (iv) four key performance indicators (KPIs) to support adherence to the CPG recommendations and audit and feedback. The full CPG document was finalized and approved with input from members of the GDG who contributed to the creation of new national accreditation standards for ASD centers by the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI).
4. Discussion
This is the first national set of clinical practice recommendations that should serve as a foundation stone in standardizing the assessment, management, and monitoring delivered to individuals on the autism spectrum in Saudi Arabia. The early identification and intervention of children with ASD are emphasized in our recommendations and follow multiple international guidelines. Although our recommendations did not provide key signs for identifying ASD, we relied on physician’s clinical judgement and on the utilization of the DSM-5 criteria to guide the diagnostic process [
15]. However, it was interesting to see that only the New Zealand’s and National Institute for Health and Care Excellence (NICE) guidelines took the effort and added red flag signs for identification [
16,
17].
Our recommendations advocate for a proper assessment of the qualification of specialists with direct interaction with such a population. This is particularly important in ABA-based interventions as evidence suggests that variables related to supervision also significantly contribute to treatment outcomes [
18]. It also aims to prevent the inconsistency in health professionals’ diagnostic practices and limit the qualification to diagnose such disorders to specific specialties. Nonetheless, the diversity and variety of such proposed specialties would make it more feasible for individuals in rural areas to receive appropriate care. However, many international guidelines (e.g., those from New Zealand and the US) have not specified qualifications or list specialties [
16,
19,
20]. The approaches and interventions of interdisciplinary teams were the emphasis of these consensus recommendations. Another subject covered by our recommendations and those from the United States and Dubai is the need to conduct a comprehensive physical examination during the developmental period, including screening for neurocutaneous disorders, dysmorphic features, and visual and hearing impairments [
20,
21].
Our recommendations suggest performing genetic evaluation for all individuals with a confirmed ASD diagnosis. Moreover, it advises conducting a chromosomal microarray analysis (CMA) if the etiology of developmental disability is unknown due to the high level of genetic variation and de novo mutations seen in 20–30% of individuals on the autism spectrum [
22]. These recommendations took into account the significance of consanguinity in Saudi culture, which was reported at one time to be present in 57.7% of marriages [
23]. This differs from the NICE and Dubai’s guidelines, which limit the recommendation for genetic evaluations to when they are deemed clinically indicated [
17,
21,
24].
Contrary to New Zealand’s guidelines, which recommends looking for other comorbidities only when a severe behavioral disturbance is evident, comorbid screening is recommended in our recommendations as well as in the NICE, and European’s for all cases suggestive of ASD [
16,
17,
25]. Although the US guidelines suggest that ASD might mask and overshadow other comorbidities, it did not recommend looking for specific diseases [
20]. Similarly, it is critical to recognize these medical issues because many of them can promote or exacerbate undesired behavior in children on the autism spectrum, and these behaviors may improve once the medical issues are managed. On a different note, the telehealth assessment of ASD has been proposed in Australian guidelines; they regulate its role and use, limiting its use but ensuring better care quality [
19]. Our recommendations did not address telehealth use as it is conceptually new in our country and is yet to be adequately regulated. However, telehealth initiatives were implemented recently by the MoH, which will facilitate providing and developing such services to individuals on the autism spectrum.
These consensus recommendations lack a clear pathway for the referring physician for a diagnostic assessment, unlike the guidelines from Australia and Dubai, which provided specific instructions for the referring and receiving healthcare providers [
19,
21]. One report that discussed this matter in New Zealand mentioned that a diagnostic pathway might complicate the process of seeking help from parents, and nearly a quarter of parents were guided down paths that delayed the eventual ASD diagnosis [
16,
26]. This highlights the importance of implementation tools and their utilization when dealing with a disorder requiring a multidisciplinary approach to its diagnosis.
In terms of medical interventions, we recommend that the intervention should be individualized, developmentally appropriate, and intensive. Our recommendations indicate that the accurate diagnosis of coexisting psychiatric conditions guide therapy. Consistent with CPGs such as NICE, Scottish Intercollegiate Guidelines Network (SIGN), Indian and expert opinion guidelines such as Dubai, and British Association of Psychopharmacology (BAP), we recommend against the routine use of medications including antipsychotics to treat the core symptoms of ASD [
27,
28,
29]. We find that medications can be helpful to address irritability, challenging behaviors, and co-occurring symptoms and/or disorders. However, they should be considered only after careful accounting of when the behavior started and what seems to exacerbate it. This is consistent with other guidelines, such as those from NICE and New Zealand [
16,
17]. The higher use of psychostimulants and antipsychotics is observed in individuals on the autism spectrum in primary health care compared with the general population [
30]. We agree with Dubai guidelines that the use of psychotropic medications should be part of a comprehensive intervention approach and not used solely [
21]. If a medication is to be prescribed for a specific indication, the prescribing clinician should carefully weigh the potential risks and benefits, which is an agreement point among all guidelines. In addition, the prescribing clinician should understand the indications and contraindications, dosing, potential adverse effects, drug–drug interactions, and monitoring requirements of the medications. We do not recommend specific medications for irritability, sleep, ADHD, or anxiety, which were included in New Zealand guidelines, Indian CPGs, and Dubai expert opinion guidelines [
16,
21,
28]. We do not limit medications to specific choices as long as they are evidence-based for reasons related to the development of our healthcare system and our approach toward an individualized plan of intervention. Alternative interventions, such as exclusion diet, secretin chelation, and hyperbaric oxygen therapy, were beyond the scope of these recommendations.
In terms of psychological interventions, our recommendations placed greater emphasis on family involvement: starting from involving the parents or caregivers in the evaluation session so they can directly observe what occurs in that session and discuss these observations with the psychologist afterward. We emphasized delineating a systematized process for defining the family’s/caregivers’ level of involvement, training duration, and expectations. This was not emphasized in other international guidelines, such as those from New Zealand, Australia, and SIGN [
16,
19,
27]. Consistent with the Dubai expert opinion guidelines, the psychoeducation provided to the parents is vital to ensure that the skills learned are generalized to different settings [
31]. In alignment with other guidelines, such as NICE and SIGN, we emphasize the importance of social communication interventions in targeting the core symptoms of autism [
17,
27]. As for behavioral interventions, in addition to parent-mediated approaches, NDBIs and approaches focused on social–pragmatic and relational skills, we recommend early intensive intervention programs (EIP) for young children aged 2–5 years, which differs from the recommendations of New Zealand’s guidelines, in which we targeted a specific age group for EIP [
16]. Given that the strongest evidence of EIP efficacy was found to be with this age group and taking into consideration the substantial limitation in the availability of the resources necessary for such programs in Saudi Arabia, we opted not to recommend such programs for older age groups [
32]. In contrast to Dubai guidelines, we did not restrict direct therapy hours of EIP to 20–40 h per week, as well as in consideration of the substantial limitation in the availability of the resources necessary for such programs in Saudi Arabia, and useful programs that may be accessible in our country may provide fewer than 20 h of EIP per week. In addition, we did not enforce requirements related to the international certification of ABA service providers to make it feasible in our society where the availability of such trained personnel is limited.
Similar to other international guidelines such as SIGN, we recommend occupational therapy interventions that emphasize social engagement and participation, developmental activities, domestic and personal skills, and encourage collaboration with speech and language pathologists (SLPs) and behavioral therapists [
27]. One of the strengths of our guidelines is that we demonstrated a model for the occupational therapy settings including equipment necessary to ensure safety, such as mats and swings and time of face-to-face interaction to ensure quality. Compared with the Dubai guideline, and while recommending the assessment and management of sensory issues, our guidelines did not specifically recommend sensory-oriented interventions such sensory integration therapy and touch therapy/massage in the management of ASD in children and adolescents due to the lack of solid evidence [
33]. In addition to occupational therapy interventions for children with ASD, we also recommended speech and language therapy for the behavioral management of feeding. We elaborated further on the facilitation of activities and participation by helping the individual acquire new communication skills or modify existing skills in addition to the utilization of family-centered practice, which was not discussed in other international guidelines such as NICE and the Indian guidelines, which is another noted strength in our recommendations [
17,
28,
29]. There are current efforts to draft the first national ASD Clinical Practice Guideline (ASD-CPG) using AGREE II Instrument and GRADE Method [
34]. The new guideline will take time to develop, and we hope these recommendations will bridge the gap until it is released.