Introduction
utism Spectrum Disorder (ASD) is a group of pervasive neurodevelopmental disorders characterized by moderate to severe impairment in social skills, socialization, repetitive and expressive language, and repetitive and stereotyped behaviors and interests [1 ,2 ,3]. Evidence shows that the prevalence of ASD is increasing [4] with an average annual increase of 10.9%: the fastest growth rate among other disabilities since 2009 [5]. In the United States, its prevalence is 1 in 54 healthy children [6]. ASD can be a costly disorder throughout a person’s life. Due to its prevalence and range of behavioral needs and characteristics of patients, rehabilitation is necessary to teach social interactions and communication skills to them and prevent the progression or exacerbation of behavioral deficits [7]. Early diagnosis and treatment are some of the most critical factors in optimizing the outcome of rehabilitation; diagnosis is a prerequisite for access of families to early interventions [8]. There are several rehabilitation interventions for patients with ASD. These people need lifelong support and strive for employment, independent living, and socialization [9]. On the other hand, rehabilitation interventions require the use of appropriate facilities and structures such as human resources, financial resources and equipment, expert support, physical space, and also the cooperation of families, especially parents [10].
As mentioned above, one of the essential needs of ASD patients and their families is to use rehabilitation services to improve their performance in said areas. However, access to and use rehabilitation services is challenging for these individuals [11, 12, 13]. Some health care providers are not ready for their clients. Some therapists report a lack of skills and tools needed to care for people with ASD [14]. The present study aims to systematically review and comprehensively classify the challenges of access to rehabilitation services for patients with ASD. It is expected that this study can provide the necessary evidence for policymakers and managers involved in the use of rehabilitation services for people with ASD to improve the living conditions of these people by solving the challenges and ultimately help improve their quality of life.
Materials and Methods
This research is a systematic review study. A search was conducted on articles published in Persian and English from 2010 to 2020 on the challenges of accessing and using rehabilitation services for people with ASD in online databases of Google Scholar, PubMed, Scopus, ProQuest, Science direct, SID, and MagIran using the keywords of “challenge”, “utilization”, “accessibility”, “rehabilitation”, “healthcare”, and “autism”. The initial search yielded 142 articles. After reviewing their titles, 102 articles were excluded because they were irrelevant or duplicates, and 40 remained. Finally, by examining the quality, methodology, and abstracts of the articles and considering the inclusion criteria, 14 studies were selected (Figure 1). A Table was prepared containing the authors’ names, study country, study time, the title of study, type of study, the purpose of study, target group, number of samples, and study results (Table 1).




The inclusion criteria were publication in reputable journals, in English or Persian, available in full-text, and publication during 2010-2020; the exclusion criterion was a letter to the editor.
Results
This study investigated the challenges of accessing rehabilitation and healthcare services for patients with ASD. Findings showed problems in the executive and information structures in rehabilitation and treatment programs for these people. Establishing a systematic monitoring system is recommended in response to these challenges. Neglecting the structure and policy of rehabilitation puts systematic rehabilitation policies in front of the implementers. On the other hand, the challenges of poor knowledge and attitudes, and ultimately the defect in the information system, are evident at various levels, such as rehabilitation service providers, parents, and the community. This condition has led to the development or exacerbation of problems in other areas, such as family despair, poor teamwork, and no commitment to professional ethics.
The findings of Płatos and Pisula in 2019 showed that despite the growing number of adolescents and young adults with ASD, there is little information about the necessary services and the existing barriers. In their study, the barriers that parents stated included difficulty in accessing services, not being eligible to receive services, difficult access to information about services, and expensive costs of services [24]. Another study reported that people with ASD had problems with the use of services, lack of regular service delivery, insufficient insurance coverage, and lack of parental involvement in childcare. These problems were more common in people with ASD than in people with other developmental and mental disorders [13]. Poor access to and use of rehabilitation services create many challenges for people with disabilities and service providers, especially in rural areas where there is a shortage of human resources and rehabilitation equipment [27, 28]. The most critical challenges were as follows:
• Challenges related to the high costs of services and the lack of a systematic support system: High cost of providing services [15], insufficient insurance coverage [13], lack of government support [26], and concerns about costs [21];
• Challenges related to rehabilitation services: Lack of availability of some essential and essential services such as occupational therapy [19], lack of access to specialists in ASD [26], and lack of special services, especially in rural areas [18];
• Challenges related to poor knowledge and attitude: Lack of knowledge of the signs and symptoms of ASD [26], lack of information of parents about how to access the required services [15], and lack of knowledge about ASD [22];
• Challenges related to the structure of rehabilitation programs: Problems in using services, such as lack of maintaining services [13], structure and maintenance of ASD services [29], and heterogeneity of services offered in different centers [15];
• Challenges related to communication between parents and service providers: Lack of parental involvement in childcare [13], difficulty communicating with service providers [21], and poor cooperation of parents and providers in planning, implementing, and evaluating services [15];
• Challenges related to screening, diagnosis, and rehabilitation: Inefficiency in diagnosing and screening people with disabilities [17], and diagnosis and treatment process [29];
• Other challenges: Defects in rehabilitation monitoring [17] and low human resources of service providers [29].
It is hoped that the results of this study help policymakers, managers, and planners in the field of rehabilitation of ASD people to help them achieve their human rights in the field of health and rehabilitation like other people in the community by reforming executive structures and developing comprehensive rehabilitation programs.
Discussion and Conclusion
Because of the nature of ASD, families, and service providers have many challenges in accessing and using rehabilitation services. These services are not provided in the entire life of people with ASD. Recognition of these challenges helps rehabilitation program managers and policymakers take more effective steps to provide services to people with ASD and their families. They should pay more attention to existing capacities, adopt, and implement the necessary programs to lead to basic measures to improve the rehabilitation services needed by people with ASD. Besides, to increase the productivity of rehabilitation services for these people, we need short-term, medium-term, and long-term planning. One of the limitations of this study is that other language articles are not reviewed due to the lack of proficiency in other languages.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1399.144).

Funding
This article has been extracted from MA. thesis of the first author at the Department of Rehabilitation Management, University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
Idea, conceptualization, editing, and finalizing: Mahta Alsadat Aarabi, Kianoush Abdi; Writing: Mahta Alsadat Aarabi; Supervision and management: Kianoush Abdi, Mohammad Saeed Khanjani.

Conflict of interest
The authors declared no conflict of interest.


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