Cross-cultural differences in gastrointestinal symptoms and sensory response in individuals with autism: A comparison of Spain and Colombia.

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Tíscar Rodríguez-Jiménez, Agustín E. Martínez-González, Diana Riaño-Hernández This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4251102/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose. Between 40 and 70% of the population with autism have been found to suffer from functional gastrointestinal disorders (FGIDs). The emergence of FGIDs is related with lower quality of life, and greater medical resources, somatization and emotional instability. There is a paucity of research available that examines gastrointestinal symptoms and sensory responses in individuals with autism in different countries and cultures. Methods. The present study analyses differences in gastrointestinal symptoms and sensory response between individuals with autism from Spain (n=65; mean age = 8.91, SD = 4.02) and Colombia (n=62; mean age = 10.16, SD = 5.31). Results. No differences were found as a function of age, sex and autism severity between Spanish and Colombian participants. More severe functional nausea and vomiting was reported by the Colombian sample when compared with the Spanish sample. Similarly, greater sensory reactivity emerged in Colombian individuals with autism relative to Spanish individuals with autism. Conclusions. Identified differences may suggest that the impact of nutritional and epigenetic factors is dependent on the cultural context. Present findings are of huge relevance to the application of treatments in different cultures based on probiotics, prebiotics and nutrition. Autism functional gastrointestinal disorders gastrointestinal symptoms constipation pain cross-cultural Introduction Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is mainly characterised by impaired communication and repetitive behaviour [ 1 ]. In addition, ASD diagnosis is associated with a number of comorbid neurodevelopmental disorders such as intellectual disability (ID) [ 1 ]. Rome IV criteria advocates for considering functional gastrointestinal disorders (FGIDs) as a set of chronic or recurrent gastrointestinal symptoms (GS) which have a gut–brain interaction [ 2 ]. Further, FGIDs were associated with lower quality of life and more frequent visits to the doctor [ 3 ], higher medical expenses, increasing somatization [ 4 ], and psychosocial difficulties [ 5 ]. Gastrointestinal symptom (GS) incidences of between 40 and 70% have been found in autistic populations [ 6 , 7 ]. A recent meta-analysis reported that 37% of children with ASD suffered from constipation, whilst 21% suffered from abdominal pain, 19% diarrhoea, 8% vomiting and 23% abdominal distension [ 8 ]. Selective or restrictive dietary patterns (e.g., picky eaters) are related to sensory response and GS in individuals with ASD [ 6 , 9 ]. Thus, GS such as constipation are more severe in individuals with ASD than neurotypical controls [ 6 ]. Further, significantly higher rates of children with ASD and GS report both anxiety and sensory over-responsivity (SOR) [ 10 ]. Similarly, associations have been found between anxiety, SOR and chronic abdominal pain, with SOR being a significant predictor of the onset of pain [ 11 ]. Thus, abdominal pain appears to be common amongst children with ASD. These results indicate that anxiety, SOR, GS and abdominal pain are possibly interrelated and may have common underlying mechanisms [ 10 , 11 ]. Several studies have highlighted the existence of a relationship between abdominal pain, selective dietary patterns, emotional instability and gut dysbiosis in neurodevelopmental disorders such as ASD. Notably, all of these aforementioned variables seem to be related to the gut–microbiota–brain axis through the enteric nervous system [ 6 , 7 , 12 , 13 , 14 ]. There is a lack of cross-cultural research available examining differences in ASD symptoms between countries [ 15 ]. Furthermore, this lack of research becomes more evident when differences in GS, a variable closely related to diet, and epigenetic factors are considered [ 8 ]. Cross-cultural differences in GS and sensory reactivity between countries have not been analysed, with this shortfall being even more stark in Latin and Hispanic countries. The aim of the present study, therefore, was to examine differences in gastrointestinal symptoms and sensory response between individuals with autism from Spain and Colombia. Methods Participants A sample of 127 (65 Spanish and 62 Colombian) individuals with ASD and their families participated in a survey. Participants came from all regions of Spain and Colombia. Participating children were enrolled at centres delivering special education, early childcare or day care, or regular schools with open classrooms. Spanish participants came from different-sized urban and rural areas in the regions of Valencia, Murcia and Andalusia. The Colombian sample came from the Andean, Caribbean, Orinoquía and Pacific regions. DSM-5 diagnostic criteria for ASD [ 1 ] served as the referent for inclusion of individuals in both the Spanish and Colombian samples. Spanish participants had previously been diagnosed by mental health services and pertinent institutions responsible for ascertaining the degree of disability and dependency. Similarly, autism diagnoses in Colombian participants were made by public and private mental health institutions (e.g., early intervention centres, autism centres, etc.). Individuals with other concomitant diagnoses, such as motor disabilities, multiple disabilities, attention-deficit/hyperactivity disorders, obsessive-compulsive disorders, neurodegenerative diseases and mental illnesses, were excluded. Understandably, participants with ASD and ID, were included when ASD was the primary diagnosis. Measures Sociodemographic questionnaire Lam and Aman's [ 16 ] sociodemographic questionnaire was adapted for the present online study. This tool consists of a series of questions about sociodemographic characteristics (e.g., age, sex, country of birth) and comorbidities (e.g., intellectual disability). Clinical questionnaire on gastro-intestinal symptoms This is an ad hoc questionnaire that was developed to identify gastro-intestinal disorders according to Rome criteria [ 2 ]. It consists of a series of questions about gastrointestinal disorders (e.g. diarrhoea, abdominal pain, dyspepsia and gastroesophageal reflux). Gastrointestinal Symptom Severity Scale (GSSS) This instrument is based on Rome IV criteria [ 2 ] and consists of seven items pertaining to main gastro-intestinal symptoms (constipation, diarrhoea, average stool consistency, stool odour, flatulence and gas, and abdominal pain). The instrument comprises an abdominal subscale (abdominal pain, gas and constipation) and a vomiting and defecation subscale (vomiting, defecation in inappropriate places, diarrhoea, rumination). Items are rated along a four-point Likert scale ranging from 0 (none/nothing or this symptom does not occur) to 3 (very frequent and troublesome). The GSSS presents adequate psychometric properties in individuals with autism and in neurotypical children and adolescents [ 17 , 18 , 19 ]. Internal consistency coefficients of .73 have been reported in children with typical development [ 19 ], whilst coefficients between .75 and .61 have been reported in individuals with autism [ 18 ]. Two versions of the instrument are available, namely, a version for caregivers-professionals and a self-report version. The caregivers-professionals version of the test was administered in the present study. Pain and sensitivity reactivity scale (PSRS) The PSRS is a tool that evaluates reactivity to pain and sensory reactivity according to 50 items. It is composed of three dimensions, namely, pain, sensory hyporeactivity and sensory hyper-reactivity. Items are rated on a four-point Likert scale ranging from 0 (behaviour does not occur) to 3 (behaviour occurs and is a severe problem). Both hyposensitivity and hypersensitivity dimensions comprise tactile, olfactory, visual, gustatory and auditory items. In addition, the PSRS includes a pain reactivity domain which comprises seven items. The PSRS was elaborated based on theoretical requisites conceived by Miller et al. [ 20 ], which characterizes sensory modulation disorders according to three patterns (hyper-response, hypo-response and sensory seeking) as proposed nosology for diagnosis. Two versions of the PSRS are available. The first is a version administered for completion by caregivers and professionals, whilst the second is a self-report version [ 21 ]. The caregiver version of the PSRS has shown excellent internal consistency in samples with ASD (pain α = .83; broad sensory hyporeactivity α = .90; broad sensory hyperreactivity α = .93) [ 22 ]. The caregiver version was used in the present study. Procedures The present study was approved by the Ethics Committee of the University of Alicante in Spain (reference: UA-2019-10-04) and the Catholic University of Pereira in Colombia (reference: UCP-2021-05). The survey was carried out using online data collected from the parents and caregivers of individuals with ASD who provided written informed consent. The reporting assessment protocol was individually applied through online survey tools, specifically, LimeSurvey (LimeSurvey GmbH, Hamburg, Germany), in Spain, and Formsite, in Colombia. Both platforms complied with the same comprehensive autism assessment protocol. For the recruitment of all participants, a cover letter containing study information was sent to ordinary centres, special education centres, associations serving families with children with autism, etc. Centre management teams informed families about the study and provided access to the online survey. Centres held an online or telematic meeting in order to timetable appointments and explain the purpose of the research. Subsequently, participating institutions contacted families to organize a meeting and further explain the purpose of the study. Similarly, some institutions provided the research team with contact information so that study researchers could directly explain the purpose of the study to families. Finally, an explanatory video was shared using social networks. All participating families and caregivers had a child diagnosed with ASD according to DSM-5 criteria [ 1 ]. Individuals with ASD, whether with or without ID, were diagnosed according to DSM-5 criteria using standardised scales (e.g., Wechsler nonverbal scale of ability, Leiter-3 scale, etc.). Participants had all been previously diagnosed by the pertinent mental health services and institutions responsible, in their given country, for establishing their degree of disability and dependency. Families with children with another type of neurodevelopmental disorder (e.g., ADHD) or with a diagnosis of ASD but who had not been assessed for possible ID were excluded from the study. With regards to individuals with ASD in Spain, diagnoses were made at early care centres and through regional paediatric services attached to local mental health centres [ 23 ]. Common standardised scales were used to reach a diagnosis of autism (e.g., communication domain of the Vineland adaptive behavior scales, Vineland adaptive behavior scales, autism diagnostic interview-revised, autism diagnostic observation schedule–generic, childhood autism rating scale, etc.). However, the diagnostic process for individuals with ASD in Colombia was applied in line with the "clinical protocol for the diagnosis, treatment and comprehensive care route for boys and girls with autism spectrum disorders" outlined by the Colombian Ministry of Health [ 24 ]. This national protocol uses applied behaviour analysis (ABA) to reach clinical and non-psychometric diagnoses. A limitation of this protocol is that most of the standardized scales used to apply it have not yet been validated and scales taken adapted from measures used with Spanish or American populations are typically used. Study researchers organised a training session for all participating centres, in which they describe in detail the purpose of the research study, the tests to be used and the process to be followed during test administration. Expert psychologists and similar professionals (educational psychologists, special education teachers, psychologists) were engaged in the administration of online tests to participating families, which sought to gather information on the perceptions and knowledge of individuals with ASD at the participating institutions that served them. Psychologists based at participating centre were on hand to help families resolve any doubts regarding their diagnosis in the first part of the survey. The explanatory video mentioned above urged families to consult pertinent psychological and psychiatric reports should any doubts exist regarding their diagnosis. The European Spanish versions of the GSSS and PSRS were revised by three specialist Colombian psychologists and one Spanish psychologist who corroborated to ensure that items were culturally equivalent. Subsequently, clarity and ease of understanding of all items were verified in a pilot study conducted with ten participants in Pereira (Colombia). This revealed that no issues emerged regarding understanding and so no linguistic adaptation was needed. Data analyses Statistical analyses were performed using IBM SPSS Statistics v 25.0 for Windows [ 25 ]. Means and standard deviations for all items corresponding to all tests were calculated for both samples from the direct scores reported by participants. Cronbach's alpha scores were calculated for all individual subscales and overall scores pertaining to the GSSS and PSRS, as a function of country. Next, as a preliminary step prior to performing the main analysis, sociodemographic variables were compared between the two countries in order to examine potential confounding factors. Chi-square analyses were conducted of the categorical variables of gender, age and comorbidity with intellectual disability (ID). For the comparison of mean values, the Kolmogorov-Smirnov test was applied to verify the normality assumption for the use of parametric tests within each group. Outcomes revealed that the normality assumption was not satisfied. As a result, the non-parametric Mann-Whitney U test was used to determine whether GSSS and PSRS subscale and overall scores differed between Spanish and Colombian participants, with significance being set at p < .05. Effect sizes associated with these differences were calculated to determine whether statistically significant differences existed between the proportions reported in each country. In this sense, .20 ≤ d ≤ .50 represented a small effect size, whilst .51 ≤ d ≤ .79 corresponded to a medium effect size and d ≥ .80 reflected a large effect size [ 26 ]. Results Sociodemographic data pertaining to all 127 participants with ASD from Spain (n = 65) and Colombia (n = 62) are presented in Table 1 . No differences were found in relation to sex (χ 2 = .00; df = 1; p = .96) and age when comparing Spanish and Colombian samples with ASD (χ 2 = .91; df = 1; p = .34). Outcomes also indicated largely similar outcomes regarding the frequency of ASD diagnosis without ID and with mild ID (χ 2 = 1.58; df = 3; p = .66). Table 1 Sociodemographic and diagnostic characteristics of the sample Spanish sample Colombian sample N 65 62 Age (M/SD) 8.91 (4.02) 10.16 (5.31) Sex (male/female) (48; 73.8%/ 17; 26.2%) (46; 74.2%/ 16; 25.8%) Reported diagnosis N % N % ASD w/o ID 50 76.9 45 72.6 ASD w Mild ID 9 13.8 10 16.1 ASD w Moderate ID 5 7.7 7 11.3 ASD w Severe ID 1 1.5 0 0 Context N % N % Regular class in a regular school 43 66.2 42 67.7 Special class in a regular school 15 23.1 9 14.5 Special School 2 3.1 1 1.6 Other (e.g.: residence, day center, etc.) 5 7.7 10 16.2 Note. w = with; w/o = without; ASD = Autism Spectrum Disorder; ID = Intellectual Disability; M = Mean; SD = Standard Deviation Insert Table 1 Around Here Gastrointestinal Symptoms A higher rate of gastrointestinal disorders was found in the Colombian sample of individuals with ASD relative to the Spanish sample. Specifically, infectious diarrhoea and gastroesophageal reflux was three times higher in the Colombian sample. However, a higher percentage of abdominal pain is seen in the Spanish sample of individuals with ASD (see Table 2 ). Table 2 Presence of gastrointestinal disorders in the individuals with ASD according to the country Gastrointestinal disorders Spanish sample (%) Colombian sample (%) Diagnosis of gastrointestinal disease 52.3 59.7 Infectious diarrhea 4.6 16.1 Nonspecific abdominal pain 20 9.7 Dyspepsia 9.2 4.8 Gastroesophageal reflux 4.6 21 Significant Flatulence 9.2 6.5 Irritable Bowel Syndrome 3.1 0 Dyschezia 0 0 Inflammatory Bowel Disease 0 3.2 Celiac Disease 0 0 Ulcerative Colitis 1.5 0 Peptic Ulcer Disease 4.6 1.6 Crohn's disease 0 0 Insert Table 2 Around Here Outcomes regarding differences in gastrointestinal symptom severity between individuals with ASD from Spain and Colombia are presented in Table 3 . With regards to gastrointestinal symptoms, the Colombian sample reported significantly higher mean scores on the functional nausea and vomiting subscale of the GSSS, with the magnitude of this difference being moderate. Table 3 Differences in gastrointestinal symptom severity of individuals with ASD according to the country GSSS Spanish sample Colombian sample M(SD) M(SD) U p d [95% CI] Abdominal pain and defecation subscale 1.78 (2.13) 1.92 (1.88) 1829.50 .35 - Functional nausea and vomiting subscale 0.45 (0.93) 0.94 (1.34) 1499.00 .00 ** 0.42[0.07–0.77] Total GSSS 2.23 (2.53) 2.85 (2.67) 1694.50 .11 - Note. GSSS = Gastrointestinal Symptom Severity Scale; M = Mean; SD = Standard Deviation; * p < .05; ** p < .01. Insert Table 3 Around Here Sensory Response Outcomes reveal that differences do not exist in the degree of pain experienced by Colombian and Spanish individuals with ASD. However, significantly higher scores were provided by Colombian participants when compared with Spanish participants with regards to sensory hyporeactivity and sensory hyper-reactivity PSRS subscale scores and overall PSRS scores. Furthermore, differences were found in all dimensions of sensory hyper-reactivity (tactile, olfactory, visual, taste and auditory). The magnitude of these differences was found to be moderate to high (see Table 4 ). Table 4 Differences in pain and sensory response of individuals with ASD according to the country PSRS Spanish sample Colombian sample M(SD) M(SD) U p d [95% CI] Pain 5.83 (2.73) 6.56 (3.66) 1895.00 .55 - Total Hypo 14.49 (9.59) 19.29 (10.74) 1438.50 .00 ** 0.47 [0.12;0.82] Hypo- Tactile 4.06 (2.98) 5.19 (3.61) 1663.00 .08 - Hypo-Olfactory 2.46 (2.73) 2.48 (2.42) 1894.00 .55 - Hypo-Visual 2.68 (2.43) 3.98 (2.70) 1379.00 .00 ** 0.50 [0.15;0.86] Hypo-Taste 2.38 (2.49) 3.13 (2.70) 1652.50 .07 - Hypo-Auditory 2.91 (2.28) 4.50 (2.64) 1312.00 .00** 0.64 [0.28;1] Total Hyper 16.66 (12.48) 26.40 (14.99) 1245.00 .00** 0.70 [0.34;1.06] Hyper-Tactile 4.22 (3.41) 6.52 (4.12) 1327.00 .00** 0.61 [0.25;0.96] Hyper-Olfactory 2.49 (2.87) 4.11 (3.64) 1499.00 .01 0.49 [0.14;0.84] Hyper-Visual 1.86 (2.69) 3.37 (2.77) 1240.00 .00** 0.55 [0.19;0.90] Hyper-Taste 3.91 (3.26) 5.53 (3.61) 1477.50 .00** 0.47 [0.12;0.82] Hyper-Auditory 4.18 (3.39 6.87 (3.67) 1199.50 .00** 0.76 [0.40;1.12] Total PSRS 36.98 (20.79) 52.26 (25.56) 1315.00 .00** 0.65 [0.30;1.01] Note. PSRS = Pain and Sensitivity Reactivity Scale; Total Hypo = Total Sensory Hyporeactivity; Total Hyper = Total Sensory Hyperreactivity; M = Mean; SD = Standard Deviation; * p < .05; ** p < .01. Insert Table 4 Around Here Discussion Descriptive outcomes reported in the present study indicate that the prevalence of gastro-intestinal disorders in autistic individuals from Spain and Colombia was around 50%. This finding mirrors that found in previous studies [ 6 , 7 , 8 ]. Similarly, the proportion of participants in the Spanish sample suffering from abdominal pain was similar to that previously reported in existing literature [ 8 ], with rates of diarrhoea in the Colombian sample also being similar to that reported by a previous study [ 8 ]. A higher prevalence of disorders related to the expulsion of food, namely, nausea, vomiting, diarrhoea and reflux was found in the Colombian sample with ASD recruited in the present study. In congruence with this finding, more severe levels of functional nausea and vomiting have been found in Colombian individuals with ASD when compared with Spanish individuals with ASD. This is elucidating in terms of the GS differences in evidence between the two countries under study given their different food culture, meal times, ways of cooking, etc [ 9 ]. This finding raises questions around whether certain bacteria could be more frequent (e.g. Blastocystis infection) in the Colombian population and lead to the emergence of the aforementioned GS [ 27 ]. This possibility must be considered in light of the fact that the present study included both urban and rural populations from Colombia. This is important because previous studies found dysbiosis in the intestinal microbiome of an indigenous population with frequent episodes of gastrointestinal infections [ 28 ]. In addition, present findings reveal more severe sensory reactivity in a Colombian population with ASD relative to a Spanish sample with ASD. This finding is in line with that reported by a previous study which found higher levels of repetitive behaviour in Colombian individuals with ASD [ 15 ]. Repetitive behaviour and sensory reactivity are highly interconnected with regards to ASD [ 1 ]. The higher level of sensory reactivity seen in Colombian individuals in the present study may be due to various aspects, such as the resources available for sensory stimulation at Colombian centres and treatment approaches [ 15 ], which could not be considered in the present study. Ultimately, findings indicate that Colombian children with autism have greater gastro-intestinal difficulties and greater sensory hyper-reactivity. It is often surmised that such symptoms are associated with alterations of the gut-microbiota [ 14 ]. However, present findings are of limited scope. It is urged that future studies include: 1) an analysis of the pyrosequencing of the 16S rRNA and comparison of samples taken from different countries; 2) a larger sample, although the recruited sample was similar in size to those used by previous studies [ 8 ]; and 3) additional variables such as the type of diet followed or food consumed. Declarations To the Editor, We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulation of our institutions concerning intellectual property. Conflict of Interest Author Tíscar. Rodríguez-Jiménez declares that he has no conflict of interest. Author Agustín E. Martínez-González declares that he has no conflict of interest. Author Diana. Riaño-Hernández declares that he has no conflict of interest. Sincerely, The authors. Competing Interests and Funding Research funded by the Ministry of science and technology and innovation and the Catholic University of Pereira. References: 844-2020 Funding Declaration Research funded by the Ministry of science and technology and innovation and the Catholic University of Pereira. References: 844-2020 Author Contribution The introduction, methods and discussion sections were written by Agustin Ernesto Martinez-González, Diana Riaño and Tiscar Rodriguez. Tiscar Rodriguez carried out the statistical analyzes. All the authors approved the final version of the manuscript. 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Lawrence Erlbaum Associates, Hillsdale, NJ Muñoz-Sánchez D, Triviño-Valencia J, Lora-Suarez F, Gómez-Marín JE (2021) Blastocystis Subtypes and Culture Characteristics of Isolates from Human Stools Related with the Presence of Gastrointestinal Symptoms: A Case-Control Study. Acta Parasitol 66:1466–1471. https://doi.org/10.1007/s11686-021-00419-y Kann S, Eberhardt K, Hinz R, Schwarz NG, Dib JC, Aristizabal A, Mendoza GAC, Hagen RM, Frickmann H, Barrantes I, Kreikemeyer B (2023) The Gut Microbiome of an Indigenous Agropastoralist Population in a Remote Area of Colombia with High Rates of Gastrointestinal Infections and Dysbiosis. Microorganisms 11:625. https://doi.org/10.3390/microorganisms11030625 Additional Declarations No competing interests reported. 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Martínez-González","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYNACA2QGewMROg4YIDN4DhCjBYUhkYBfNX//GuPPHwruMPCLHX4GYsjJz3xj+IGhog6nFokbb8wkDhg8Y5CcnWY8A8gwZpydYyzBcOYwbmtunDEDeuEwg8HtBGMQI7FZOsdAgrENt4fkb5wx/gDSYn87/TNIS32b5BnjH4z/cDvM4HyPgQTYFukcsC0JPBI8ZhKMDcw4tRjeYCuTOGNwmEfidk4xA5BhOIMnrcwi4Rhuv8idP7z5Q8Wfw3L8s9M3MwAZ8vLthzff+FCD22GwWOBBFU3ArQEYMQfwyY6CUTAKRsEoAAIAR5FXq/oE5Y4AAAAASUVORK5CYII=","orcid":"","institution":"University of Alicante","correspondingAuthor":true,"prefix":"","firstName":"Agustín","middleName":"E.","lastName":"Martínez-González","suffix":""},{"id":291359841,"identity":"840856de-6f0f-425f-8702-af190663d2da","order_by":2,"name":"Diana Riaño-Hernández","email":"","orcid":"","institution":"Catholic University of Pereira","correspondingAuthor":false,"prefix":"","firstName":"Diana","middleName":"","lastName":"Riaño-Hernández","suffix":""}],"badges":[],"createdAt":"2024-04-11 08:20:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4251102/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4251102/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57203640,"identity":"e9217afb-e8ce-4e57-b1ea-63a12ab1172e","added_by":"auto","created_at":"2024-05-27 10:33:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":585771,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4251102/v1/cbfec1a3-27e1-450a-a3cb-abc53c74fef5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cross-cultural differences in gastrointestinal symptoms and sensory response in individuals with autism: A comparison of Spain and Colombia.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAutism spectrum disorder (ASD) is a neurodevelopmental disorder that is mainly characterised by impaired communication and repetitive behaviour [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, ASD diagnosis is associated with a number of comorbid neurodevelopmental disorders such as intellectual disability (ID) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRome IV criteria advocates for considering functional gastrointestinal disorders (FGIDs) as a set of chronic or recurrent gastrointestinal symptoms (GS) which have a gut\u0026ndash;brain interaction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Further, FGIDs were associated with lower quality of life and more frequent visits to the doctor [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], higher medical expenses, increasing somatization [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and psychosocial difficulties [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGastrointestinal symptom (GS) incidences of between 40 and 70% have been found in autistic populations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A recent meta-analysis reported that 37% of children with ASD suffered from constipation, whilst 21% suffered from abdominal pain, 19% diarrhoea, 8% vomiting and 23% abdominal distension [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Selective or restrictive dietary patterns (e.g., picky eaters) are related to sensory response and GS in individuals with ASD [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Thus, GS such as constipation are more severe in individuals with ASD than neurotypical controls [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Further, significantly higher rates of children with ASD and GS report both anxiety and sensory over-responsivity (SOR) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Similarly, associations have been found between anxiety, SOR and chronic abdominal pain, with SOR being a significant predictor of the onset of pain [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Thus, abdominal pain appears to be common amongst children with ASD. These results indicate that anxiety, SOR, GS and abdominal pain are possibly interrelated and may have common underlying mechanisms [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Several studies have highlighted the existence of a relationship between abdominal pain, selective dietary patterns, emotional instability and gut dysbiosis in neurodevelopmental disorders such as ASD. Notably, all of these aforementioned variables seem to be related to the gut\u0026ndash;microbiota\u0026ndash;brain axis through the \u003cem\u003eenteric nervous system\u003c/em\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a lack of cross-cultural research available examining differences in ASD symptoms between countries [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, this lack of research becomes more evident when differences in GS, a variable closely related to diet, and epigenetic factors are considered [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Cross-cultural differences in GS and sensory reactivity between countries have not been analysed, with this shortfall being even more stark in Latin and Hispanic countries. The aim of the present study, therefore, was to examine differences in gastrointestinal symptoms and sensory response between individuals with autism from Spain and Colombia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eA sample of 127 (65 Spanish and 62 Colombian) individuals with ASD and their families participated in a survey. Participants came from all regions of Spain and Colombia. Participating children were enrolled at centres delivering special education, early childcare or day care, or regular schools with open classrooms. Spanish participants came from different-sized urban and rural areas in the regions of Valencia, Murcia and Andalusia. The Colombian sample came from the Andean, Caribbean, Orinoqu\u0026iacute;a and Pacific regions.\u003c/p\u003e \u003cp\u003eDSM-5 diagnostic criteria for ASD [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] served as the referent for inclusion of individuals in both the Spanish and Colombian samples. Spanish participants had previously been diagnosed by mental health services and pertinent institutions responsible for ascertaining the degree of disability and dependency. Similarly, autism diagnoses in Colombian participants were made by public and private mental health institutions (e.g., early intervention centres, autism centres, etc.).\u003c/p\u003e \u003cp\u003eIndividuals with other concomitant diagnoses, such as motor disabilities, multiple disabilities, attention-deficit/hyperactivity disorders, obsessive-compulsive disorders, neurodegenerative diseases and mental illnesses, were excluded. Understandably, participants with ASD and ID, were included when ASD was the primary diagnosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eSociodemographic questionnaire\u003c/h2\u003e \u003cp\u003eLam and Aman's [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] sociodemographic questionnaire was adapted for the present online study. This tool consists of a series of questions about sociodemographic characteristics (e.g., age, sex, country of birth) and comorbidities (e.g., intellectual disability).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eClinical questionnaire on gastro-intestinal symptoms\u003c/h2\u003e \u003cp\u003eThis is an ad hoc questionnaire that was developed to identify gastro-intestinal disorders according to Rome criteria [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It consists of a series of questions about gastrointestinal disorders (e.g. diarrhoea, abdominal pain, dyspepsia and gastroesophageal reflux).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eGastrointestinal Symptom Severity Scale (GSSS)\u003c/h2\u003e \u003cp\u003eThis instrument is based on Rome IV criteria [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and consists of seven items pertaining to main gastro-intestinal symptoms (constipation, diarrhoea, average stool consistency, stool odour, flatulence and gas, and abdominal pain). The instrument comprises an abdominal subscale (abdominal pain, gas and constipation) and a vomiting and defecation subscale (vomiting, defecation in inappropriate places, diarrhoea, rumination). Items are rated along a four-point Likert scale ranging from 0 (none/nothing or this symptom does not occur) to 3 (very frequent and troublesome). The GSSS presents adequate psychometric properties in individuals with autism and in neurotypical children and adolescents [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Internal consistency coefficients of .73 have been reported in children with typical development [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], whilst coefficients between .75 and .61 have been reported in individuals with autism [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Two versions of the instrument are available, namely, a version for caregivers-professionals and a self-report version. The caregivers-professionals version of the test was administered in the present study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003cem\u003ePain and sensitivity reactivity scale (PSRS)\u003c/em\u003e\u003c/h2\u003e \u003cp\u003eThe PSRS is a tool that evaluates reactivity to pain and sensory reactivity according to 50 items. It is composed of three dimensions, namely, pain, sensory hyporeactivity and sensory hyper-reactivity. Items are rated on a four-point Likert scale ranging from 0 (behaviour does not occur) to 3 (behaviour occurs and is a severe problem). Both hyposensitivity and hypersensitivity dimensions comprise tactile, olfactory, visual, gustatory and auditory items. In addition, the PSRS includes a pain reactivity domain which comprises seven items. The PSRS was elaborated based on theoretical requisites conceived by Miller et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], which characterizes sensory modulation disorders according to three patterns (hyper-response, hypo-response and sensory seeking) as proposed nosology for diagnosis. Two versions of the PSRS are available. The first is a version administered for completion by caregivers and professionals, whilst the second is a self-report version [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The caregiver version of the PSRS has shown excellent internal consistency in samples with ASD (pain α\u0026thinsp;=\u0026thinsp;.83; broad sensory hyporeactivity α\u0026thinsp;=\u0026thinsp;.90; broad sensory hyperreactivity α\u0026thinsp;=\u0026thinsp;.93) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The caregiver version was used in the present study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003e The present study was approved by the Ethics Committee of the University of Alicante in Spain (reference: UA-2019-10-04) and the Catholic University of Pereira in Colombia (reference: UCP-2021-05). The survey was carried out using online data collected from the parents and caregivers of individuals with ASD who provided written informed consent. The reporting assessment protocol was individually applied through online survey tools, specifically, LimeSurvey (LimeSurvey GmbH, Hamburg, Germany), in Spain, and Formsite, in Colombia. Both platforms complied with the same comprehensive autism assessment protocol.\u003c/p\u003e \u003cp\u003eFor the recruitment of all participants, a cover letter containing study information was sent to ordinary centres, special education centres, associations serving families with children with autism, etc. Centre management teams informed families about the study and provided access to the online survey. Centres held an online or telematic meeting in order to timetable appointments and explain the purpose of the research. Subsequently, participating institutions contacted families to organize a meeting and further explain the purpose of the study. Similarly, some institutions provided the research team with contact information so that study researchers could directly explain the purpose of the study to families. Finally, an explanatory video was shared using social networks. All participating families and caregivers had a child diagnosed with ASD according to DSM-5 criteria [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Individuals with ASD, whether with or without ID, were diagnosed according to DSM-5 criteria using standardised scales (e.g., Wechsler nonverbal scale of ability, Leiter-3 scale, etc.). Participants had all been previously diagnosed by the pertinent mental health services and institutions responsible, in their given country, for establishing their degree of disability and dependency. Families with children with another type of neurodevelopmental disorder (e.g., ADHD) or with a diagnosis of ASD but who had not been assessed for possible ID were excluded from the study.\u003c/p\u003e \u003cp\u003eWith regards to individuals with ASD in Spain, diagnoses were made at early care centres and through regional paediatric services attached to local mental health centres [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Common standardised scales were used to reach a diagnosis of autism (e.g., communication domain of the Vineland adaptive behavior scales, Vineland adaptive behavior scales, autism diagnostic interview-revised, autism diagnostic observation schedule\u0026ndash;generic, childhood autism rating scale, etc.). However, the diagnostic process for individuals with ASD in Colombia was applied in line with the \"clinical protocol for the diagnosis, treatment and comprehensive care route for boys and girls with autism spectrum disorders\" outlined by the Colombian Ministry of Health [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This national protocol uses applied behaviour analysis (ABA) to reach clinical and non-psychometric diagnoses. A limitation of this protocol is that most of the standardized scales used to apply it have not yet been validated and scales taken adapted from measures used with Spanish or American populations are typically used. Study researchers organised a training session for all participating centres, in which they describe in detail the purpose of the research study, the tests to be used and the process to be followed during test administration.\u003c/p\u003e \u003cp\u003eExpert psychologists and similar professionals (educational psychologists, special education teachers, psychologists) were engaged in the administration of online tests to participating families, which sought to gather information on the perceptions and knowledge of individuals with ASD at the participating institutions that served them. Psychologists based at participating centre were on hand to help families resolve any doubts regarding their diagnosis in the first part of the survey. The explanatory video mentioned above urged families to consult pertinent psychological and psychiatric reports should any doubts exist regarding their diagnosis.\u003c/p\u003e \u003cp\u003eThe European Spanish versions of the GSSS and PSRS were revised by three specialist Colombian psychologists and one Spanish psychologist who corroborated to ensure that items were culturally equivalent. Subsequently, clarity and ease of understanding of all items were verified in a pilot study conducted with ten participants in Pereira (Colombia). This revealed that no issues emerged regarding understanding and so no linguistic adaptation was needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analyses\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics v 25.0 for Windows [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Means and standard deviations for all items corresponding to all tests were calculated for both samples from the direct scores reported by participants. Cronbach's alpha scores were calculated for all individual subscales and overall scores pertaining to the GSSS and PSRS, as a function of country. Next, as a preliminary step prior to performing the main analysis, sociodemographic variables were compared between the two countries in order to examine potential confounding factors. Chi-square analyses were conducted of the categorical variables of gender, age and comorbidity with intellectual disability (ID). For the comparison of mean values, the Kolmogorov-Smirnov test was applied to verify the normality assumption for the use of parametric tests within each group. Outcomes revealed that the normality assumption was not satisfied. As a result, the non-parametric Mann-Whitney U test was used to determine whether GSSS and PSRS subscale and overall scores differed between Spanish and Colombian participants, with significance being set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05. Effect sizes associated with these differences were calculated to determine whether statistically significant differences existed between the proportions reported in each country. In this sense, .20\u0026thinsp;\u0026le;\u0026thinsp;\u003cem\u003ed\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;.50 represented a small effect size, whilst .51\u0026thinsp;\u0026le;\u0026thinsp;\u003cem\u003ed\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;.79 corresponded to a medium effect size and \u003cem\u003ed\u003c/em\u003e\u0026thinsp;\u0026ge;\u0026thinsp;.80 reflected a large effect size [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSociodemographic data pertaining to all 127 participants with ASD from Spain (n\u0026thinsp;=\u0026thinsp;65) and Colombia (n\u0026thinsp;=\u0026thinsp;62) are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. No differences were found in relation to sex (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.00; \u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.96) and age when comparing Spanish and Colombian samples with ASD (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.91; \u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.34). Outcomes also indicated largely similar outcomes regarding the frequency of ASD diagnosis without ID and with mild ID (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.58; \u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.66).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSociodemographic and diagnostic characteristics of the sample\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSpanish sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eColombian sample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (M/SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8.91 (4.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e10.16 (5.31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e(48; 73.8%/\u003c/p\u003e \u003cp\u003e17; 26.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e(46; 74.2%/\u003c/p\u003e \u003cp\u003e16; 25.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReported diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD w/o ID\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD w Mild ID\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD w Moderate ID\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASD w Severe ID\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContext\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegular class in a regular school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecial class in a regular school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecial School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (e.g.: residence, day center, etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote.\u003c/em\u003e w\u0026thinsp;=\u0026thinsp;with; w/o\u0026thinsp;=\u0026thinsp;without; ASD\u0026thinsp;=\u0026thinsp;Autism Spectrum Disorder; ID\u0026thinsp;=\u0026thinsp;Intellectual Disability; M\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard Deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e Around Here\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eGastrointestinal Symptoms\u003c/h2\u003e \u003cp\u003eA higher rate of gastrointestinal disorders was found in the Colombian sample of individuals with ASD relative to the Spanish sample. Specifically, infectious diarrhoea and gastroesophageal reflux was three times higher in the Colombian sample. However, a higher percentage of abdominal pain is seen in the Spanish sample of individuals with ASD (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ePresence of gastrointestinal disorders in the individuals with ASD according to the country\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal disorders\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpanish sample\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eColombian sample\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis of gastrointestinal disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfectious diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonspecific abdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspepsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastroesophageal reflux\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant Flatulence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritable Bowel Syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyschezia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInflammatory Bowel Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeliac Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUlcerative Colitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeptic Ulcer Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCrohn's disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e Around Here\u003c/p\u003e \u003cp\u003eOutcomes regarding differences in gastrointestinal symptom severity between individuals with ASD from Spain and Colombia are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. With regards to gastrointestinal symptoms, the Colombian sample reported significantly higher mean scores on the functional nausea and vomiting subscale of the GSSS, with the magnitude of this difference being moderate.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDifferences in gastrointestinal symptom severity of individuals with ASD according to the country\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGSSS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpanish sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eColombian sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM(SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM(SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ed\u003c/em\u003e [95% CI]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain and defecation subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.78 (2.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.92 (1.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1829.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional nausea and vomiting subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.45 (0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.94 (1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1499.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.00\u003cem\u003e**\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.42[0.07\u0026ndash;0.77]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal GSSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.23 (2.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.85 (2.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1694.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote.\u003c/em\u003e GSSS\u0026thinsp;=\u0026thinsp;Gastrointestinal Symptom Severity Scale; \u003cem\u003eM\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard Deviation; * p\u0026thinsp;\u0026lt;\u0026thinsp;.05; ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e Around Here\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSensory Response\u003c/h2\u003e \u003cp\u003eOutcomes reveal that differences do not exist in the degree of pain experienced by Colombian and Spanish individuals with ASD. However, significantly higher scores were provided by Colombian participants when compared with Spanish participants with regards to sensory hyporeactivity and sensory hyper-reactivity PSRS subscale scores and overall PSRS scores. Furthermore, differences were found in all dimensions of sensory hyper-reactivity (tactile, olfactory, visual, taste and auditory). The magnitude of these differences was found to be moderate to high (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDifferences in pain and sensory response of individuals with ASD according to the country\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePSRS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpanish sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eColombian sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM(SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM(SD)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cem\u003ed\u003c/em\u003e [95% CI]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5.83 (2.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.56 (3.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1895.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Hypo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14.49 (9.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.29 (10.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1438.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00\u003cem\u003e**\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.47 [0.12;0.82]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypo- Tactile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4.06 (2.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.19 (3.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1663.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypo-Olfactory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.46 (2.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.48 (2.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1894.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypo-Visual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.68 (2.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.98 (2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1379.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00\u003cem\u003e**\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.50 [0.15;0.86]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypo-Taste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.38 (2.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.13 (2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1652.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypo-Auditory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.91 (2.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.50 (2.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1312.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.64 [0.28;1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Hyper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e16.66 (12.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.40 (14.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1245.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.70 [0.34;1.06]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyper-Tactile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4.22 (3.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.52 (4.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1327.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.61 [0.25;0.96]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyper-Olfactory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2.49 (2.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.11 (3.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1499.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.49 [0.14;0.84]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyper-Visual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1.86 (2.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.37 (2.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1240.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.55 [0.19;0.90]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyper-Taste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3.91 (3.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.53 (3.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1477.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.47 [0.12;0.82]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyper-Auditory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4.18 (3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.87 (3.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1199.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.76 [0.40;1.12]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PSRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e36.98 (20.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.26 (25.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1315.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.00**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.65 [0.30;1.01]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eNote.\u003c/em\u003e PSRS\u0026thinsp;=\u0026thinsp;Pain and Sensitivity Reactivity Scale; Total Hypo\u0026thinsp;=\u0026thinsp;Total Sensory Hyporeactivity; Total Hyper\u0026thinsp;=\u0026thinsp;Total Sensory Hyperreactivity; \u003cem\u003eM\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard Deviation; * p\u0026thinsp;\u0026lt;\u0026thinsp;.05; ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e Around Here\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDescriptive outcomes reported in the present study indicate that the prevalence of gastro-intestinal disorders in autistic individuals from Spain and Colombia was around 50%. This finding mirrors that found in previous studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, the proportion of participants in the Spanish sample suffering from abdominal pain was similar to that previously reported in existing literature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], with rates of diarrhoea in the Colombian sample also being similar to that reported by a previous study [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA higher prevalence of disorders related to the expulsion of food, namely, nausea, vomiting, diarrhoea and reflux was found in the Colombian sample with ASD recruited in the present study. In congruence with this finding, more severe levels of functional nausea and vomiting have been found in Colombian individuals with ASD when compared with Spanish individuals with ASD. This is elucidating in terms of the GS differences in evidence between the two countries under study given their different food culture, meal times, ways of cooking, etc [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This finding raises questions around whether certain bacteria could be more frequent (e.g. \u003cem\u003eBlastocystis\u003c/em\u003e infection) in the Colombian population and lead to the emergence of the aforementioned GS [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This possibility must be considered in light of the fact that the present study included both urban and rural populations from Colombia. This is important because previous studies found dysbiosis in the intestinal microbiome of an indigenous population with frequent episodes of gastrointestinal infections [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e In addition, present findings reveal more severe sensory reactivity in a Colombian population with ASD relative to a Spanish sample with ASD. This finding is in line with that reported by a previous study which found higher levels of repetitive behaviour in Colombian individuals with ASD [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Repetitive behaviour and sensory reactivity are highly interconnected with regards to ASD [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The higher level of sensory reactivity seen in Colombian individuals in the present study may be due to various aspects, such as the resources available for sensory stimulation at Colombian centres and treatment approaches [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which could not be considered in the present study.\u003c/p\u003e \u003cp\u003eUltimately, findings indicate that Colombian children with autism have greater gastro-intestinal difficulties and greater sensory hyper-reactivity. It is often surmised that such symptoms are associated with alterations of the gut-microbiota [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, present findings are of limited scope. It is urged that future studies include: 1) an analysis of the pyrosequencing of the 16S rRNA and comparison of samples taken from different countries; 2) a larger sample, although the recruited sample was similar in size to those used by previous studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; and 3) additional variables such as the type of diet followed or food consumed.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eTo the Editor,\u003c/p\u003e\n\u003cp\u003eWe confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.\u003c/p\u003e\n\u003cp\u003eWe confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulation of our institutions concerning intellectual property.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflict of Interest\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAuthor T\u0026iacute;scar. Rodr\u0026iacute;guez-Jim\u0026eacute;nez declares that he has no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor Agust\u0026iacute;n E. Mart\u0026iacute;nez-Gonz\u0026aacute;lez declares that he has no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor Diana. Ria\u0026ntilde;o-Hern\u0026aacute;ndez declares that he has no conflict of interest.\u003c/p\u003e\n\u003cp\u003eSincerely,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests and Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch funded by the Ministry of science and technology and innovation and the Catholic University of Pereira. References: 844-2020\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch funded by the Ministry of science and technology and innovation and the Catholic University of Pereira. References: 844-2020\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe introduction, methods and discussion sections were written by Agustin Ernesto Martinez-Gonz\u0026aacute;lez, Diana Ria\u0026ntilde;o and Tiscar Rodriguez. Tiscar Rodriguez carried out the statistical analyzes. All the authors approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric Publishing, Washington, DC\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrossman DA, Hasler WL (2016) Rome IV-functional GI disorders: disorders of gut-brain interaction. 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Microorganisms 11:625. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/microorganisms11030625\u003c/span\u003e\u003cspan address=\"10.3390/microorganisms11030625\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Autism, functional gastrointestinal disorders, gastrointestinal symptoms, constipation, pain, cross-cultural","lastPublishedDoi":"10.21203/rs.3.rs-4251102/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4251102/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose. Between 40 and 70% of the population with autism have been found to suffer from functional gastrointestinal disorders (FGIDs). The emergence of FGIDs is related with lower quality of life, and greater medical resources, somatization and emotional instability. There is a paucity of research available that examines gastrointestinal symptoms and sensory responses in individuals with autism in different countries and cultures. Methods. The present study analyses differences in gastrointestinal symptoms and sensory response between individuals with autism from Spain (n=65; mean age = 8.91, SD = 4.02) and Colombia (n=62; mean age = 10.16, SD = 5.31). Results. No differences were found as a function of age, sex and autism severity between Spanish and Colombian participants. More severe functional nausea and vomiting was reported by the Colombian sample when compared with the Spanish sample. \u0026nbsp;Similarly, greater sensory reactivity emerged in Colombian individuals with autism relative to Spanish individuals with autism. Conclusions. Identified differences may suggest that the impact of nutritional and epigenetic factors is dependent on the cultural context. Present findings are of huge relevance to the application of treatments in different cultures based on probiotics, prebiotics and nutrition.\u003c/p\u003e","manuscriptTitle":"Cross-cultural differences in gastrointestinal symptoms and sensory response in individuals with autism: A comparison of Spain and Colombia.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-16 10:20:05","doi":"10.21203/rs.3.rs-4251102/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c386be20-44de-4120-b967-110abe409999","owner":[],"postedDate":"April 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-27T10:25:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-16 10:20:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4251102","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4251102","identity":"rs-4251102","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}