Neurodevelopmental Comorbidities in Children with Autism Spectrum Disorder in Saudi Arabia: A Systematic Review and Meta-Analysis

Autism spectrum disorder (ASD) is frequently associated with multiple neurodevelopmental comorbidities that significantly influence clinical outcomes and care needs. This review aimed to assess the prevalence and types of neurodevelopmental comorbidities among children with autism spectrum disorder in Saudi Arabia through a systematic review of the literature and meta-analysis. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, electronic databases including PubMed, Scopus, and the Saudi Digital Library were searched for observational studies involving Saudi children with autism spectrum disorder aged 0-18 years. Data were extracted on common comorbidities such as attention-deficit/hyperactivity disorder (ADHD), intellectual disability (ID), and epilepsy. A random-effects model was used to estimate pooled prevalence, and the methodological quality of included studies was assessed. Twelve studies, including 2,025 children with autism spectrum disorder, demonstrated a substantial burden of comorbid conditions. The pooled prevalence of attention-deficit/hyperactivity disorder was 62.1%, with considerable heterogeneity (I² = 87%), largely influenced by differences in diagnostic methods. The overall prevalence of epilepsy was 10.3%, with marked variation between hospital-based samples (31.6%) and general clinic samples (2-8%), suggesting potential ascertainment bias. Evidence regarding intellectual disability was inconsistent; one study reported a prevalence of 8%, while another reported a mean intelligence quotient within the intellectual disability range (57.56), indicating possible under-identification. Other commonly reported comorbidities included sleep problems (36.7%) and gastrointestinal problems (54.3%), although language and motor impairments were insufficiently evaluated across studies. Overall, neurodevelopmental comorbidities are common among Saudi children with autism spectrum disorder, particularly attention-deficit/hyperactivity disorder and epilepsy. However, existing evidence is limited by methodological heterogeneity, referral bias, and inconsistent diagnostic practices, leading to wide variation in reported estimates. These findings highlight the need for standardized, multidisciplinary assessment approaches and population-based research to better define the burden of comorbidities and support the development of appropriate healthcare services.