Tunisia Issues First National Clinical Guideline for Children and Adolescents with Autism

Tunisia has published its first national clinical practice guideline for the screening, diagnosis, and management of autism spectrum disorder in children and adolescents, a document that brings 96 evidence-based recommendations and 87 good practice points into a single framework adapted to the country’s healthcare system. The guideline was developed by the Tunisian Society of Child and Adolescent Psychiatry and received the official label of the National Authority for Evaluation and Accreditation in Healthcare following independent methodological and clinical review. It is organized into ten chapters covering screening, diagnosis, etiological investigation, intervention, pharmacological treatment, education, complementary and alternative treatments, associated conditions, follow-up and prognosis, support for caregivers, and professional training, and it is intended for use across all levels of care in both the public and private sectors.

The need for a unified national standard is grounded in the country’s own data. The World Health Organization estimates the prevalence of autism in children at approximately 1 in 100, a figure that varies considerably across populations because of differences in diagnostic practices, case identification, and access to services. In Tunisia, a descriptive multicenter cross-sectional study conducted in 2022, which included 918 children aged 18 to 36 months, reported an autism prevalence of 1.01 percent, with a 95 percent confidence interval of 0.35 to 1.65 percent. The article describing the guideline notes that child and adolescent mental health services in Tunisia face important organizational challenges, including an unequal geographical distribution of specialized professionals and limited coordination between the health, education, and social sectors, which affects equitable access and continuity of care.

The development process followed the ADAPTE framework, a methodological tool that allows existing recommendations to be adapted to a new context while respecting the principles of evidence-based medicine. A protocol outlining objectives, the PIPOH question, the search strategy, eligibility criteria, appraisal methods, and grading approaches was approved by the national accreditation authority before work began. In March 2024, the methodological team searched the Guidelines International Network, the websites of NICE, SIGN, IACAPAP, and ESCAP, and the PubMed, Trip Database, and Embase databases, identifying 295 records before deduplication. Eleven guidelines were assessed in full text; five met the predefined eligibility criteria and were appraised with the AGREE II instrument by two trained methodologists, who resolved discrepancies item by item through discussion until full consensus was reached.

Four of the five candidate guidelines scored above 66 percent in the AGREE II domain covering rigour of development, while the ESCAP guideline scored 31 percent in that domain and was not retained as the primary source. Although the NICE guideline achieved a high overall assessment, the working group selected the 2023 Singapore clinical practice guideline on autism spectrum disorder as the primary source document. The decision rested not on the overall score alone but on a combined consideration of methodological rigour, recency, comprehensiveness, and alignment with the predefined PIPOH framework. The Singapore guideline, updated in June 2023, was the most recent of the eligible guidelines and is a single integrated document, whereas the relevant NICE material for children and adolescents is distributed across two separate guidelines of differing vintages. Formal authorization to adapt the Singapore guideline was obtained from the College of Paediatrics and Child Health, Singapore.

Each recommendation from the source guideline was assessed for consistency between the scientific evidence and the recommendation, and then for acceptability and applicability within the Tunisian context, considering the availability of specialists, regional disparities in service provision, the organization of the healthcare and education systems, the availability of validated screening and diagnostic tools, locally approved pharmacological treatments, existing intervention programmes, and implementation feasibility. On this basis, recommendations were adopted without modification, adapted to the Tunisian context, or developed de novo. Of the 183 statements in the final guideline, 157, or 85.8 percent, were adopted unchanged, 20, or 10.9 percent, were adapted, and 6, or 3.3 percent, were developed de novo. For recommendations requiring adaptation or new development, an additional literature search incorporated high-level evidence published between June 2023 and January 2025. A grading framework distinguishes strong recommendations, conditional recommendations, and good practice points, with the conditional category introduced by the working group to formalize a distinction already implicit in the source guideline’s phrasing.

The clinical content emphasizes early identification and comprehensive assessment. Monitoring for early signs of autism is to be integrated into a national developmental surveillance program, and children presenting specific warning signs, such as any regression or loss of language or social skills, absence of babbling or response to name by around 12 months, or absence of single words or pretend play by 18 months, should be promptly referred for comprehensive developmental evaluation. Targeted screening may be considered in children with risk factors, including a history of autism in a sibling, prematurity below 35 weeks of gestation, birth weight below 2500 grams, neonatal hypoxic-ischemic encephalopathy, a known genetic syndrome associated with autism, in-utero exposure to maternal antiepileptic medication, advanced parental age, or parental history of mental health disorders, the last intended solely as a prompt for heightened vigilance rather than a criterion for diagnosis. The systematic use of autism-specific screening tools in the general pediatric population without identified risk factors is not recommended, and screening tools cannot confirm or exclude a diagnosis on their own. Diagnosis should rely on internationally recognized classification systems and a holistic developmental profile rather than on autism-specific diagnostic instruments alone.

The guideline also addresses contested etiological claims and intervention choices. Current evidence does not support a causal association between autism and maternal use of paracetamol during pregnancy, epidural analgesia during labour, or childhood vaccinations, and children should follow the recommended immunization schedule, including the MMR vaccine. Routine screening for heavy metal levels is not recommended, as no causal relationship has been established, although testing for mercury or lead toxicity may be considered in specific clinical circumstances. On interventions, evidence syntheses of early interventions in young children indicate beneficial effects for some developmental and behavioral outcomes, although the magnitude and consistency of effects vary across intervention types, outcomes, and individual characteristics. Augmentative and alternative communication should be tailored to individual needs, communication-focused interventions may enhance joint attention and language, and early intensive behavioral intervention and naturalistic developmental behavioral interventions may improve adaptive, cognitive, social communication, and play skills. The use of weighted vests is not recommended because of insufficient evidence of benefit and concerns regarding potential risks.

Pharmacological recommendations are deliberately conservative. Methylphenidate should be considered as a first-line treatment for attention-deficit/hyperactivity disorder in this population, always in combination with non-pharmacological interventions. Risperidone may be used in the short term to manage irritability or hyperactivity, but the evidence is insufficient to support long-term use beyond six months, and it may cause weight gain and sedation. Melatonin may be considered for sleep disorders when psychosocial interventions are ineffective. Selective serotonin reuptake inhibitors should not be used to treat core symptoms of autism but may be prescribed for co-occurring psychiatric disorders by a qualified specialist, and a wide range of agents, including acamprosate, bumetanide, memantine, N-acetylcysteine, intranasal oxytocin, balovaptan, mTOR inhibitors, cannabinoids, and suramin, should not be used to treat core symptoms. Most complementary and alternative interventions, including gluten-free or casein-free diets, vitamin and mineral supplementation, stem cell therapy, hyperbaric oxygen therapy, chelation therapy, neurofeedback, and facilitated communication, are not recommended for core symptoms due to lack of benefit and potential harm, while music therapy, physical activity, and mindfulness may be offered as complementary supports for overall well-being.

On education and long-term follow-up, the guideline emphasizes school inclusion and individualized support based on each student’s specific needs rather than solely on diagnosis, with educational accommodations tailored to the child’s developmental profile, strengths, preferences, and family context. Parents should receive early information about school inclusion measures, generally around the age of five years, and adolescents and their families should receive information about post-school pathways and employment support. Children and adolescents with autism should receive regular, holistic follow-up given increased risks of neuropsychological, adaptive, academic, and medical difficulties, with comprehensive hearing assessment recommended for all children with suspected autism. Poorer prognosis is associated with greater severity of autistic traits in childhood, co-occurring intellectual disability, and delayed language development, and supportive family environments and positive parenting are associated with improved developmental outcomes.

The authors acknowledge several limitations. People on the autism spectrum and self-advocates were not involved in the earlier stages of scope definition, recommendation formulation, or contextual adaptation, although an autistic service user, caregivers, and a Ministry of Education representative contributed during external review by a 17-member multidisciplinary reading group. The guideline was developed in French, which may limit accessibility for some families, and simplified French and Arabic versions have been developed for caregivers, teachers, and other non-medical stakeholders. The supplementary evidence search ended in January 2025, and the limited availability of published Tunisian epidemiological and long-term outcome data meant that some contextual information relied on grey literature. Implementation will begin with dissemination and initial training within six months of publication, prioritizing primary care pediatricians and general practitioners, with broader integration over the following 18 months, a two-year evaluation through practice audits, and updates every five years or earlier if substantial new evidence emerges.

Subject of Research: Development of the first national clinical practice guideline for autism spectrum disorder in children and adolescents in Tunisia

Article Title: Development and contextual adaptation of the first national clinical practice guideline for autism spectrum disorder in children and adolescents in Tunisia

Article References: Ayoub, R., Ben Abid, H., Bourgou, S., Hadj Kacem, I., Halayem, S., Khemekhem, K., Charfi, F., & Bouden, A. (2026). Development and contextual adaptation of the first national clinical practice guideline for autism spectrum disorder in children and adolescents in Tunisia. Frontiers in Psychiatry, 17, Article 1926851. https://doi.org/10.3389/fpsyt.2026.1926851

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1926851

Keywords: autism spectrum disorder, clinical practice guideline, Tunisia, ADAPTE framework, AGREE II, screening, diagnosis, child and adolescent psychiatry, Singapore guideline, health policy, evidence-based medicine, care pathways