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Current state of knowledge on the prevalence of neurodevelopmental disorders in childhood according to the DSM-5: a systematic review in accordance with the PRISMA criteria

Abstract

Objective

To interpret the current evidence on the prevalence of neurodevelopmental disorders (NDDs) through a systematic review based on both DSM-5 (2013) and PRISMA criteria.

Method

Empirical studies complying with the PRISMA guidelines were identified from four databases (PubMed, Scopus, Science Direct, and ProQuest) and systematically reviewed. In total, 17 articles were selected for the study.

Results

In the scientific literature, there have been only a few studies measuring the prevalence of NDDs according to the DSM-5 (2013) criteria in people under 18 years old. The reported prevalence rates were as follows: intellectual disability (ID), 0.63%; attention-deficit/hyperactivity disorder (ADHD), 5–11%; autism spectrum disorder (ASD), 0.70–3%; specific learning disorder (SLD), 3–10%; communication disorders (CDs), 1–3.42%; and motor disorders (MDs), 0.76–17%. Although there is extensive literature on specific disorders, NDDs have rarely been assessed as a whole.

All of the reviewed studies support the idea that such disorders can be considered chronic, heterogeneous, underdiagnosed conditions and that comorbidity of multiple NDDs is the norm. Likewise, it is estimated that the prevalence of the most studied disorders, such as ADHD, ASD and SLD, remains stable over time and is consistent in different cultures, ages, ethnicities and sexes.

Conclusion

The studies reviewed lead us to conclude that the prevalence rate of NDDs fluctuates globally between 4.70 and 88.50%; these variations depend on methodological aspects such as estimation procedures, as well as on sociocontextual phenomena. It is also important to consider that the prevalence found is probably highly influenced by the activity of the countries in the diagnosis and training of professionals who care for children and adolescents. Hence, there is a need for a secondary intervention in the fields of public health and education to minimize socioemotional consequences, prevent academic failure, and reduce the economic cost to society.

Background

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association, 2013) introduced a new diagnostic category called neurodevelopmental disorders (NDDs), a group of disorders that commonly begin in childhood and can be chronic conditions that persist for life.

This new approach is committed to the inclusion of NDDs within a heterogeneous and dimensional group, leaving behind the categorical classifications of the DSM 4th Edition Text Revision (DSM-IV-TR; American Psychiatric Association, 2004) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992). It is expected that the next ICD edition (ICD-11) will unify its criteria with those of the DSM-5 (2013). Finally, a revised DSM-5 (i.e. DSM-5-TR) will also be published in 2022.

As mentioned above, the category of NDDs includes disorders that manifest in a general way in almost all developmental domains, such as intellectual disability (ID), as well as those that affect more specific domains, such as attention-deficit/hyperactivity disorder (ADHD), autistic spectrum disorder (ASD), communication disorders (CD), specific learning disorder (SLD, including difficulties in reading, writing and mathematics), and motor disorders (MDs, such as Tics, Tourette's and stereotypic disorders), among others.

The current detection rates of developmental disorders are lower than their real prevalence, according to Zwaigenbaum and Penner [1]. A study by Petersen et al., 2014, noted that these disorders affect 15–20% of the child population, which is why they constitute a common reason for consultation in childhood and adolescence.

In the United States, according to data published by the National Center for Health Statistics (NCHS) in 2015, an estimated 15% of children aged 3 to 17 years are affected by NDDs.

In previous studies, the prevalence rates of the most common NDDs were estimated as follows: ADHD = 7.9–9.5% [3, 4]; ASD = 0.7–2.2% [4,5,6]; SLD (or developmental dyslexia [DD]) = 1.2–24% [7, 8]; and motor coordination disorder = 1.4–19% [9, 10]. Furthermore, the prevalence rates reported for various disorders within the same study did not include the rates of coexistence between disorders [11]. Likewise, there is disparity and diversity in the methods used by the scientific community to estimate prevalence. To determine the prevalence of these disorders, surveys have been applied to different populations (general, clinical, school), and different professionals have performed the assessments (medical specialists, teachers, school counsellors); very few studies have assessed and directly examined the individuals, with most studies merely extrapolating conclusions from specific clinical and/or population databases. In this way, studies reach conclusions that may reflect certain inherent biases. Therefore, according to Thomas R. et al. [2, 3, 11], systematic reviews would be one of the best solutions to this problem.

Clinical experience leads us to believe that it is rare for a single NDD to occur in isolation; rather, there is overlap between different disorders (homotypic comorbidity) and with other psychiatric psychopathologies (heterotypic comorbidity). The study of NDDs as a whole and in the context of their comorbidities is necessary to approximate clinical reality and to estimate the true scope of each specific disorder. Finally, it is possible that various target disorders are initially masked in some patients but become clinically apparent with age [12, 13].

Patients and methods

This work is a review of the published scientific literature on paediatrics, child and adolescent psychiatry and all journals related to NDDs, specifically in relation to the epidemiology of NDDs as defined by the DSM-5 (2013).

The review follows the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration for the correct performance of systematic reviews [14] PRISMA are considered a formal research process that ensures replicability in the results. It aims to provide a solid and universal protocol for systematic review and documents reviews transparently. See Fig. 1, Flow Chart.

Fig. 1
figure 1

Flow chart

The selection process identified 17 articles that were deemed appropriate. These articles report on aspects of the prevalence of NDDs worldwide, spanning Asia, Europe, Australia, the USA, Latin America and Africa. Such breadth is important, considering the possible effects of socioeconomic resources on the diagnosis and development of certain conditions.

Methodologically, the studies collected their information from a variety of sources: surveys (of parents and/or teachers), diagnostic records in health systems, records from special schools, and records of prescribed pharmacological treatments provided by public health systems and private insurance (USA). However, the possible biases of our selection methods must be considered, since, in the included meta-analyses, different meta-analytical techniques are used to estimate and unify prevalence rates by group and homogenize the samples, which vary depending on geographical areas, sex, ethnicity, and population type.

The data in the included studies were collected according to various diagnostic criteria; the most widely used are the DSM-IV-TR and ICD-10 manuals. The change in criteria with the publication of the DSM-5 (2013) compels us to consider the possibility that the literature reflects a persistent underdiagnosis of comorbidities (Additional file 1).

Results

Tables and graphs will be inserted throughout the text to facilitate an understanding of the data.

The analysis that we will present below is arranged in the order that we consider the most appropriate to facilitate an understanding of the subject, and we have attempted to integrate and distil the results into simple and understandable points. The main results are shown in Summary Table 1.

Table 1 Summary table

We will present the global selection of studies by diagnostic themes in the following order:

Studies regarding NDDs in general:

Seven studies evaluated the global prevalence of NDDs; 6 of these works were prevalence studies, and the remaining one was a systematic review and meta-analysis. In a systematic review and meta-analysis [15], the prevalence of NDDs was estimated in low- and middle-income countries (hereafter, LAMIC); it was concluded that the burden of NDDs in LAMIC is considerable and that there is a lack of reliable epidemiological data on some NDDs, such as ASD, which may lead to underestimation of the true burden of these conditions in LAMIC. Mental disorders such as ADHD and ASD have rarely been reported, and more studies are needed, particularly in Africa and Latin America, to provide reliable estimates, as neurological conditions such as epilepsy generally have more reliable estimates than mental disorders.

In 2021, the research group of Bosch et al. [16] published the first study reporting the prevalence rates of all NDDs in Spain; the rates were determined through direct examinations of 6834 students aged 5–17 years from 28 schools in Catalonia. The study concluded that these conditions were underdiagnosed, and the following prevalence rates were obtained: ID, 0.63%; CD, 1.05%; ASD, 0.70%; ADHD, 9.92%; SLD, 10.0%; and MD, 0.76%.

In India, a study published by Arora et al. [17] in 2018 assessed the prevalence of several NDDs: visual impairment, epilepsy, neuromotor disability (including cerebral palsy), hearing impairment, speech and language disorders, ASD and ID. Additionally, children aged 6 to 9 years were screened for ADHD and learning disorders. The prevalence of NDDs varied between locations. The site-specific prevalence of these seven classes of NDDs in children aged 2 to 6 years ranged from 2.9% to 18.7%, while children aged 6 to 9 years showed a 6.5% to 18.5% prevalence of the nine NDDs. Hearing impairment and ID were the most common NDDs. Approximately one-fifth of children with NDDs suffer from two or more. The pooled estimates for NDDs across all sites for NDDs were 9.2% and 13.6% in children ranging from 2 to 6 and 6 to 9 years, respectively, with no significant differences by gender, rural/urban residence, or religion. Hearing impairment, ID, speech and language disorders, epilepsy, and learning disorders were found to be common NDDs across all sites. Among children with NDDs, 21.7% had two or more; comorbid NDDs were most common in children with ASD (79.6%), cerebral palsy (74.2%), ID (56.9%) and epilepsy (55.1%).

In Japan, Kita et al. [11] conducted the first study measuring comorbidity among ADHD, ASD, SLD (DD) and CD. Oppositional defiant disorder (ODD) was also evaluated due to its high comorbidity with ADHD. The results indicated that 0.4% of children had comorbid ADHD, ASD and SLD. The prevalence rates of ADHD ranged from 6.3% to 6.5% depending on the rating methods. The parent-reported ASD prevalence rate was approximately 1.9%.

The comorbidity rates between ADHD and other disorders were 1.1% for ASD and 0.6% for dyslexia or SLD with reading and writing difficulties, according to parent-completed rating scales. These rates were not significantly different from those based on teacher rating scales: 2.1% (ADHD × ASD) and 1.2% (ADHD × dyslexia; P = 0.09 and 0.23, respectively). Regarding triple comorbidity, the parents reported that 0.2% of the children had concurrent ADHD, ASD, and dyslexia, which was lower than the rate evaluated by their teachers (P < 0.001).

In Scotland, Fleming et al. [18] estimated the prevalence rates of ASD, ID, ADHD and depression. The results indicated neurodevelopmental comorbidity (2 of these conditions) in 0.6% of the children, with ASD and ID being the most common combination.

A total of 4.7% had at least one of the interest conditions, and 0.6% had 2 or more conditions. Of the children who had ASD, 33.0% had at least one other condition. Of the children with ADHD, 29.2% had at least one comorbidity. Of the children with ID, 16.5% had comorbidities, and of the children with depression, 10.6% had comorbidities.

The most common combination was ASD with ID, which occurred in 0.3% of children; 81.0% of the children with this combination were boys. Multimorbidity was the most common form of coexisting ASD and ID. ADHD, by itself or coexisting with other conditions, was the factor with the greatest weight in increasing exclusion from school. Multimorbidity was more common among men, with the prevalence increasing with deprivation. Girls were less likely to have multimorbidity, although with a greater negative impact on educational outcomes compared to boys.

In Norway, Hansen et al. [19] estimated the prevalence rates of NDDs (ADHD, tic disorder (TD), ASD, and homotypic and heterotypic comorbid disorders). Children with NDDs constituted 55.5% of children referred to Child and Adolescent Mental Health Services (CAMHS).

Prevalence estimates for ADHD ranged from 20.8% to 44.5%, TD from 1.8% to 17.7%, and ASD from 2.3 to 10.3%. Despite the different diagnostic procedures between studies, ADHD clearly appears to be the most frequent NDD found. One or more NDDs were diagnosed in 55.5%, of whom 69.9% were boys; ADHD in 44.5%, of whom 68.5% were boys; TD in 17.7%, of whom 77.8% were boys; and ASD in 6.1%, of whom 76% were boys. Among children with NDDs, 31.0% had only one NDD without a comorbid disorder, 21.7% had more than one NDD, and 58% had a comorbid non-NDD psychiatric disorder. Males constituted a significant majority of referred children (66.3%).

In Spain, Carballal et al. [20] studied the prevalence of infants through adolescent psychiatric pathology in primary care consultations with follow-up by infant-juvenile mental health units. They found that the most frequent pathologies were ADHD (5.36%), language disorders (3.42%), learning disorders (3.26%), anxiety and depressive disorders (2.4%) and conduct disorders (1.87%). Forty-seven percent had comorbidities with another mental disorder; most of these children required multiprofessional care in the social, health and educational fields, and 33% received psychopharmacological treatment.

Studies regarding ADHD:

ADHD continues to be the most studied NDD; accordingly, this study was able to locate 4 systematic reviews and meta-analyses on the topic. The most relevant findings are summarized in the attached summary table. In China (Wang et al., 2017) [21], the overall combined prevalence of ADHD among children and adolescents was 6.26%. In Spain, the overall combined prevalence of ADHD was estimated at 6.8% [22, 23] estimated that the global prevalence of ADHD is 5%, with a peak at 9 years, and suggested that the range reported in the community prevalence of ADHD (2.2–7.2%) reflects the variation in the study methodology.

The World Federation of ADHD International Consensus Statement study [24] found that 5.9% of young people meet the diagnostic criteria for ADHD. That study did not find an increase in the prevalence of ADHD in children and adolescents over the past three decades. In black youth under 18 years of age, an ADHD prevalence of 14% was obtained. Additionally, ADHD was more common in male youth than in female youth (2:1).

Studies regarding ASD:

Our review included 2 articles on the topic of ASD. A recent study carried out in Catalonia [25] revealed an overall ASD prevalence of 1.23% in 2017, with 1.95% for boys and 0.46% for girls. The highest prevalence (1.80%) was found in children from 11 to 17 years old. Overall, the prevalence of ASD observed in that study was 1.23%, with a male:female ratio of 4.5:1, which is consistent with previous studies. Saito et al. [26] carried out a study assessing ASD and comorbid NDDs in 5-year-old children in Japan according to the DSM-5 (2013); they determined that the adjusted prevalence of ASD was 3.22%. Only 11.5% of children with ASD were free of comorbid NDDs; the remaining 88.5% had at least one other NDD (that is, ADHD, developmental coordination disorder (DCD), ID, and/or borderline intellectual functioning). Notably, 23% of children with ASD also had two other NDDs concurrently.

Studies regarding the prevalence of child and adolescent psychopathology:

Carballal et al. [20] and Dalsgaard et al. [27] examined the prevalence of child and adolescent psychopathology; these studies are commented on in the summary table.

Other topics of interest regarding diagnostic approaches:

See the summary table for comments on the work of Shriberg et al. [28], Fortes S. et al. [29] and Murphy et al. [30].

Conclusions

The objective of this systematic review was to determine the prevalence of NDDs to estimate their global prevalence. Few studies have considered the DSM-5 classification (APA, 2013); our review found only 2 such studies [16, 26].

The criteria used by the different publications varied greatly, and the processes used to measure the indicators were often not made explicit. There has been little direct assessment and diagnostic certainty in the clinical population. Furthermore, studies usually did not take into account the complexity and comorbidities of the disorders studied; instead, disorders tended to be analysed individually. Secondary sources are important as complementary resources for diagnosis, and prevalence studies with direct sources are lacking. This review identified only five studies that clearly calculated the prevalence of NDDs through direct examinations of the studied population [16, 26, 29] and covered the most prevalent disorders within the NDD group according to the DSM-5 (2013). Two other studies [28, 30] examined the populations directly but did not follow the DSM-5 (2013) criteria and included smaller samples. In the other studies chosen, the prevalence tended to be established by indirect approximations. The authors consider that with the use of direct assessments, more reliable prevalence rates would be obtained, probably detecting more cases. The authors predict that direct evaluation and the use of DSM-5 criteria would increase the prevalence of NDDs.

In Spain, studies on the prevalence of NDDs are scarce, despite their importance for establishing a health system based on holistic prevention and targeting from the foundations of the problem, with a cyclical approach that looks beyond a single cause–effect relationship and considers all the circumstances that accompany the clinical manifestations. Assessing the context is as important as—or even more important than—assessing the symptoms themselves.

It is important to recognize certain distinctions, such as clinical populations vs. the general population, rural vs. urban settings, and different levels of socioeconomic resources.

In our review of NDD prevalence studies, we noted that multimorbidity was the norm, as determined by Kita [11] in Japan, Bitta (2018) [15] in low-resource countries, Fleming (2020) [18] in Scotland, Carballal (2017) [20] in Spain and Hansen (2018) in Norway [19].

We also observed that the prevalence remained stable over time in different cultures, ages, ethnicities (Faraone et al., 2020) [24], socioeconomic strata, community types (rural or urban) and religions [17].

Likewise, we found that the differences in sex were consistent, with males being more affected by general psychiatric psychopathology, as reflected in the contributions of Fleming [18] and Dalsgaard [27]. With respect to the studied NDDs and their comorbidities, 66.3% of children included in Hansen's study [19] were male, and Saito [26] reported a male:female ratio of 2.2:1. With respect to ADHD, male:female ratios of 4:1 and 2:1 have been determined (Catalá-López, 2012) [22], generally coinciding with the ratios reported (3–2:1) in the studies by Sayal [23] and Faraone [24]. Finally, in children with ASD, the study by Pérez-Crespo [25] reported a male:female ratio of 4.5:1.

Regarding the variability in the global prevalence of NDDs, the prevalence of single NDDs has been found to range from 4.70% in Scotland [18] to 55.5% in Norway [19] to 88.50% in Japan [11]. It is important to note the possible influence of methodological factors, such as the direct evaluation of children in Japan and Norway, as well as the activity of the countries in detection and diagnosis, with NDDs tending to be underdiagnosed in developing countries. In addition, it would be necessary to analyse the lack of impact of our work with the publication of the DSM-5-TR and how this new version could affect the prevalence of NDDs.

The symptomatology of a disorder is partially a reflection of its context—that is, it is dependent on a combination of internal (genetic) and external (environmental) influences. It is a dialogue between the contextual and the biological, between the social and the individual. The combination of these factors necessitates a multifactorial consideration of epidemiological, clinical and molecular findings in complex diagnoses such as NDDs.

Although it is known that epigenetic changes associated with diseases occur throughout life, the labile nature of the epigenetic state during the first stages of development makes this time especially significant and decisive.

Due to the exponential increase in consultations related to neurodevelopmental problems in paediatrics, we consider it pertinent to carry out and promote studies in real-world populations through direct examinations of the children. Early intervention is essential to improve prognosis and early diagnosis.

Availability of data and materials

We have data and materials accessible through the main author. Correspondence about the manuscript should be addressed to Dr. Lorena Francés-Soriano.

Abbreviations

NDD:

Neurodevelopmental disorder

ID:

Intellectual disability

ADHD:

Attention-deficit/hyperactivity disorder

ASD:

Autism spectrum disorder

SLD:

Specific learning disorder (e.g., dyslexia)

CD:

Communication disorder

MD:

Motor disorder

TS:

Tourette’s syndrome

TD:

Tic disorder

DCD:

Developmental coordination disorder

DD:

developmental dyslexia

DLD:

Developmental language disorder

ODD:

Oppositional defiant disorder

SLI:

Specific language impairment

LAMIC:

Low- and middle-income countries

CAMHS:

Child and Adolescent Mental Health Services

DSM-5:

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

ICD-10:

International Statistical Classification of Diseases and Related Health Problems, 10th Revision

ICD -11 :

International Statistical Classification of Diseases and Related Health Problems, 11th Revision

WHO:

World Health Organization

APA:

American Psychiatric Association

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Acknowledgements

We thank the research team (Arrels Center) for making this review and study possible through their hard work and altruistic dedication; we also thank the Balearic Islands’ Health System and the Menorca Health Area for providing support during the process. Furthermore, we thank the Menorquin Institute of Studies (IME), Balearic Islands, for financially supporting our research entitled “Prevalence of neurodevelopmental disorders in primary care consultations of the Child–Adolescent Program on the island of Menorca in boys and girls aged 6 years”. This review is intended to be a preamble to the study that is currently in progress. Finally, we thank all the professionals, including paediatricians, statisticians and nurses, who have altruistically dedicated time to this study.

Funding

The aforementioned study was approved by the Ethics Committee of the Balearic Islands in December 2020 and obtained research funding from the Menorquin Institute of Studies (IME). The approval can be viewed in BOIB (Official Balearic Islands Gazette) number 128 (September 16, 2021) at the following URL: http://www.ime.cat/WebEditor/Pagines/file/BOIB-Aprovaci%C3%B3%20ajuts%20IME%202021.pdf

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AR was present throughout the review process and focused on statistical analysis. JC and LF both reviewed all articles during the search. GF reviewed the eligible articles. JQ, FA and AH reviewed the final article and gave their approval. All authors read and approved the final manuscript.

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Correspondence to Lorena Francés.

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We declare that the ethical standards of good practice are met as a specific requirement. This review is part of a research project approved by the Ethics Committee of the Balearic Islands.

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All authors have approved the manuscript and agree with its presentation in Child and Adolescent Psychiatry and Mental Health.

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Francés, L., Quintero, J., Fernández, A. et al. Current state of knowledge on the prevalence of neurodevelopmental disorders in childhood according to the DSM-5: a systematic review in accordance with the PRISMA criteria. Child Adolesc Psychiatry Ment Health 16, 27 (2022). https://doi.org/10.1186/s13034-022-00462-1

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  • DOI: https://doi.org/10.1186/s13034-022-00462-1

Keywords

  • Neurodevelopmental disorders
  • Prevalence
  • Childhood
  • Diagnosis
  • Autism spectrum disorder
  • ADHD
  • Learning disability
  • Language disorder
  • Motor disorders
  • Intellectual disability