The Intersection of Faith and Neurodiversity: Unraveling Religiosity in Autistic Adolescents—A Critical Review Analysis

This literature review aims to explore religiosity, faith, and related beliefs in autistic adolescents. The term religiosity was used interchangeably with various related concepts such as faith, spirituality, and religious beliefs, and a broader, multifaceted approach encompassing the cognitive, subjective, social, cultural, and emotional domains of religiosity is analyzed in this population subgroup. In alignment with the neurodiversity paradigm, this review endeavors to adopt an inclusive lens toward autism spectrum conditions, appreciating the spectrum of cognitive and behavioral differences and highlighting the importance of recognizing strengths and challenges alike, reflecting the nuanced discourse surrounding neurodiversity and autism spectrum conditions. However, terms such as "high-functioning autism" and "disorder" were used where needed to reflect the journals included in the review. A systematic search was conducted by accessing academic search engines such as APA PsycInfo, APA PsycArticles, APA PsycTests, and PubMed. Only peer-reviewed articles written in English and performed on human subjects were included using strict inclusion and exclusion criteria. Several recurring themes were identified from the 13 articles selected after review for relevance and quality. The most important finding was the association of different terminologies and features while exploring “religiosity in autism.” Thirty-nine key themes were identified, which were grouped into six major themes. These were religious faith, spirituality, and its expression in autistic adolescents; religious behaviors and practices of autistic adolescents; cognition and religion in autistic teens; social and cultural influences on religiosity in autistic young ones; parents' and carers' influence, perspectives, and experiences about faith and spirituality on autistic adolescents; and perceived benefits of faith to autistic teens: parents and adolescent perspectives. Looking at the concept of religiosity and spirituality as a whole, it can be inferred from the available research included in this review that religiosity (cognitive abilities, behaviors, and experiences) in a subset of autistic adolescents (high-functioning autism) might not be significantly subdued as compared to neurotypical adolescents. However, there is not enough research to conclude the same or the opposite for autistic adolescents in general. When found, reserved religiosity could be attributed to a plethora of factors, and decreased mental ability or mentalization, empathy, or imagination did not seem to be the sole or primary predictors or contributors to religiosity. The role of culture, parents, carers, and religious affiliations was significant and might be a stronger contributor to religiosity and its expression than other previously argued predictors like mentalization. Many autistic teens and their carers regard religiosity and spirituality as essential domains in their and their children's lives, want their children to be given opportunities to be a part of religious groups and affiliations, and look forward to government, religious, and healthcare authorities actively supporting them in this domain. The findings call for policymakers, religious leaders, and stakeholders to devise strategies for inclusion and support for autistic adolescents. The possible role of religion as a resource and coping strategy for these children and their families is worth exploring.


Introduction And Background
Adolescence is a transitional period characterized by change.Along with hormonal, physical, and emotional development, there is a shift from childhood to adulthood.Many adolescents find this difficult, often becoming alienated when entering the adult world [1].Developmental science does not typically investigate religion and spirituality [2].Researchers have maintained that spirituality is an integral part of everyday human lives and is relatively central to adolescent development [2][3][4].Recently, there has been an increasing interest in the interaction between religiousness, spirituality, and disease [5].Neurodevelopmental disorders are recognized as one of the leading causes of morbidity in children and contribute significantly to the global burden of disease (GBD) [6].
According to a recent review, approximately one out of every 100 children has autism spectrum disorder (ASD), and there has been a continuous increase in the prevalence estimates over time [7].The etiology is multifactorial; however, brain imaging studies do report neurobiological abnormalities in autism, like diminished integrity of gray matter neurons and lowered glutamatergic activity in the cortex and cerebellum [8].It is also observed that religious and spiritual attitudes are affected in patients with various neurobiological abnormalities since the integrity of neuronal pathways is integral to forming and understanding various concepts, including those around spirituality and religiosity.However, the exact mechanism is unknown [5].

Definitions and terminologies
Determining what religion is can be complex [9].The terms religiosity and spirituality will be used interchangeably in this research paper.Researchers have used various terminologies to define the neurodivergent conditions "autism" and "autism spectrum disorder."The review supports a neuroaffirmative approach, promoting a more inclusive and accepting view.However, various other terminologies will be referred to when needed while referring to the work of various researchers included in the review.
Attempting to describe the broadest range of religiosity, Bergan and McConatha defined religiosity as having multiple dimensions related to various religious beliefs and practices [10], and for research purposes, we will keep referring to this definition.
"Religiosity refers to the various dimensions associated with religious beliefs and involvement.More recent studies have stressed the importance of evaluating religiosity as a multidimensional concept focusing on subjective, cognitive, behavioral, social, and cultural components."

Religiosity and autism
Autism [11] and religiosity [12] are both complex and multifaceted phenomena.Various studies have explored the relationship between autism and religiosity, some suggesting that autistic traits might be negatively associated with religiosity [13].In contrast, others cite negligible differences in the religious behaviors or cognitions of these individuals when compared to neurotypical (NT) individuals [14].
The GBD study revealed that over one million children living in South Asia and Sub-Saharan Africa are autistic.As of 2018, India has the highest number of autistic children (851,000), followed by China (422,000), Nigeria (207,000), Pakistan (172,000), and Indonesia (159,000) [15].Most of these areas and regions favor or prefer religion in one form or another.For example, Pakistan and Nigeria are declared as Islamic states, and Indonesia, though it declares itself a secular state, harbors the world's largest Muslim population [16].
Although currently there are very few autism prevalence studies from the Middle East and Africa, they reveal that the prevalence of autism ranges somewhat between 20.35/10,000 in Oman [17] to 114/10,000 in Qatar [18] and 290/10,000 in East Nigeria [19], which is comparable to or higher than the global prevalence of 230/10,000 [20] despite arguments that autism is underrepresented in these regions due to issues of inadequate diagnostic services [21], poor adaptation of diagnostic criteria with regard to cultural differences in behavior, and undersampling due to lack of reliable national data [22].
The study of religion shows that religious leaders and religion play an important role in the lives of many people, including those studied in the UK [23,24].Although sometimes religious beliefs can affect whether families are seeking a diagnosis or not, they were seen as providing emotional and social support to the cases and families of autistic people in many instances.Reportedly, religion gave the family the strength to carry on and accept the diagnosis in some instances [23].Similarly, a study on people of color, Asians, and ethnic minority groups in the UK revealed that belief systems played a significant role in autism diagnosis acceptance [24].It was postulated that faith might give the parents of autistic children strength and hope for the future [23].
Despite the observed supportive impact, the misconceptions about autism held by different religious faiths are common and sometimes unhelpful.They could have a negative outcome, affecting the well-being of autistic people and their families [24].In extreme cases, it has been suggested that autism is caused by demonic spirits or magical beings, which might alarmingly give rise to harmful treatment practices like exorcism [25].It is not unheard of that some religious figures stress that parents should rely solely on prayer to treat the disorder [24].Some places of worship might limit the inclusion of autistic people, giving them a feeling of isolation [26].
A literature search reveals that there is little research on the religious beliefs of autistic individuals [27].What little there is suggests that autistic people vary in their beliefs, with some being more firmly attached to religious faith than others [28].One study found that people who have more features of autism are less likely to believe in God than those who do not have such traits [29].
A study by Stuger [30] has shown that autistic individuals can hold strong religious beliefs and are often more faithful than their nonautistic peers.Additionally, it postulated that autistic individuals may tend to stick to traditional religious beliefs than their nonautistic counterparts [30].Yet another study found that autistic people may have a different relationship with religious beliefs than nonautistic individuals [31].Moreover, some studies have suggested that creativity can be seen as a field of relationship between God the Creator and autistic people [32,33], with each person bringing unique perspectives to the discussion.Although researchers have found that religion might offer a framework for comprehending existential anxieties and daily life's ups and downs in NT individuals [34], no concrete evidence suggests the same for autistic individuals.
Researchers focusing on the religious perspective of high-functioning autistic (HFA) individuals proposed that, instead of there being a deficit, HFAs' thinking styles are on a continuum with NTs [35].Some researchers concluded that atheism and agnosticism are supported more frequently by individuals with HFA than by NT individuals.The authors likened them to scientists with a high rejection rate for religious beliefs [36].Some believed that the HFAs appreciated socially welcoming religious communities, while others considered them rigid and doctrinaire [37].Despite the variety of opinions in this regard, most of the work implies that research into the beliefs of autistic individuals is essential in understanding the potential impact of religious beliefs on their lives [36].
Researchers have maintained that spirituality is an integral part of everyday human life [2] and is relatively central to NT adolescent development [4].During this time, spiritual assessment, examination, and consideration are often undertaken [38].According to research, religious discussions happen during late adolescence in NT individuals.Additionally, early adolescence is the period when religious commitments are formed [39].Furthermore, religion is considered an essential component of identity [40], with religious identity being formed in late adolescence [41][42][43][44][45][46][47][48].Considering that adolescence is a distinct period of transition with its unique challenges and in NT adolescents, a period when religiosity [49][50][51][52][53][54][55][56][57] and religious identity are being formed [58][59][60][61][62], understanding the presence of religion and related concepts and their significance, if any, in this particular age group is of paramount importance.Not much published data throw light on the degree of religiosity that this particular patient population holds.

Research methodology
The final search was done using the terms: 1. Autism: autism OR Asperger OR "pervasive developmental" OR Kanner* OR "high functioning autism" and 2. Religion: religion OR spiritual OR faith OR secular OR atheist OR Religious experience OR "religious belief" OR "belief system" OR "religious cognition" OR prayer 3. Adolescent: adolescents OR teenagers OR young adults OR teens OR youth OR young people

Inclusion and Exclusion Criteria
The research articles whose central theme was spirituality with the debarment of religious dimensions were not included because a person can be spiritual without being religious.For this research, the focus was on religiosity, and it included the papers with spirituality as a theme in dimensions of religiosity while excluding the ones studying spirituality individually [42].The search was carried out from 1995 to date.The preliminary exploratory literature review and research suggested that since the middle of the 1990s, the amount of research on religiosity/spirituality and health has increased [43], so the search was limited to this time frame.Only peer-reviewed articles written in English and performed on human subjects were included.

Information Sources and Search Strategy
The academic search engines accessed were APA PsycInfo, APA PsycArticles, APA PsycTests, and PubMed.An additional Google Scholar search was conducted to include any missed articles, details of which are provided in the search strategy section and summarized in Figure 1.

Screening of Records
The initial search on APA PsycInfo, APA PsycArticles, and APA PsycTests returned 117 records (after removing duplicates), while that on PubMed returned 77.The articles after applying limiters were (n = 58).The number of articles included for basic screening was n = 136, and for duplicate record removal, it was n = 68.None was returned from APA PsycTests.

TABLE 2: PubMed search results
All returned records, along with complete citation details and an abstract, were transferred from the database to Zotero, a program for managing bibliographies, where duplicate records were eliminated.After removing duplicates, the total number of articles to be screened was 68.

Screening of Article Abstracts
To decide whether to include relevant articles, a relevance decision scheme was formulated to screen the 68 article abstracts from the initial search.Each abstract was screened and either excluded or included accordingly (Table 3).

TABLE 3: Abstract screening algorithm
About 51 articles were excluded because they were not in English, their central themes were not relevant, two were book chapters, and others did not target the specified population group.Seventeen final articles were selected for a full-text review to assess their quality and determine inclusion.

Full-Text Review for Relevance and Quality
The full text of the remaining 17 records was located and reviewed.It was reviewed for relevance and quality using questions detailed in Table 4.

S.
no.

TABLE 4: Algorithm for screening full texts for relevance and quality
After reading the full texts, four further studies were excluded.One addressed spirituality exclusively, one targeted disabilities broadly, and two did not address the relevant theme.This yielded a total of 13 studies for final inclusion in the analysis.Figure 1 provides a Preferred Reporting Items for Systematic reviews and Meta-Analyses flow diagram of the search and screening processes.

Assessment of Study Quality
Studies yielded a mix of various methodologies, ranging from surveys and comparison analysis to qualitative interviews and mixed-method studies.All articles included were peer-reviewed.The articles included a good mix of perspectives from the autistic adolescents and the parents' and caregivers' reports (Table 5).

Results and findings
Several key findings emerged from this research, the most important of which was the association of different terminologies and features with "religiosity in autism."It was represented under many titles such as "Autism, Theism, and Atheism" [31], "The Place of Faith in Autism" [44], "Mentalizing Deficits, Cognition, and Autism" [14,45], "Quality of Life in Autism" [46,47], "Sensory supernatural experiences in autism" [48], "Religion and Positive Youth Development" [28], "Religious and Spiritual Expressions of Young People with Disabilities" [49], "Children with Autism in Sunday School" [50], "Religious cognition in autism" [32], and "Youth Ministry and disabilities" [51].Regardless of the variation in terminology, the studies presented findings that highlight the importance of research on religiosity in autistic adolescents.

Measures of Religiosity
The researchers used a wide variety of tools to capture these themes depending on their research questions and study feasibility.Some measures were parent reports, surveys, or interviews (6/13), while the rest collected data directly from autistic adolescents.
Six studies used open-ended questions to lead qualitative interviews tailored according to the participants and study theme.One researcher used an innovative method by asking the participants to prepare their interview by taking photographs of whatever objects, places, persons, etc. they considered were related to religion or spirituality in their lives and then bringing them to the interview and talking about them [31].The remaining researchers used various measures, such as modifying and extracting related items of religiosity from preexisting validated tools while assuring their internal validity [14,49], using a self-constructed nonvalidated religiosity measure [45], using a validated short form [46] of the "Santa Clara Strength of Religious Faith Questionnaire" [52], and extracting relevant data from a national survey of children's health [47] or an adapted version of the "intuitive religious belief scale" [53].

Key Themes
After analyzing the articles in detail, the main findings were extracted, and descriptive data were organized in table form.The key results were extracted.Thirty-nine key themes were identified and grouped into six major groups for discussion purposes.Most of the themes were recurring and overlapping and could be placed in multiple groups.The following are the six main groups, each comprising various subthemes.
1. Religious faith, spirituality, and its expression in autistic adolescents.
2. Religious behaviors and practices of autistic adolescents.
3. Cognition and religion in autistic adolescents.
4. Social and cultural influences on religiosity in autistic adolescents.
5. Parents' and caregivers' influence, perspective, and experiences about faith and spirituality in autistic adolescents.
6. Perceived benefits of faith to autistic adolescents: parents and adolescent perspectives.

Discussion
The review highlighted an interesting array of findings regarding religiosity in autistic adolescents.The most prominent finding was the vastness of religiosity, related concepts, terminologies, and the interplay of various domains of life and the sciences, in the lifespan of autistic adolescents.Observable external religious behaviors and practices, as well as deep-rooted internal feelings and personal experiences, were studied in the target population.The findings demonstrated that numerous factors interplayed to shape the experience and manifestation of religiosity in this population group (Table 6).The main themes  Religion is a multidimensional concept that expands over several life domains: social, personal, and emotional.It is understandable, therefore, that a certain set of basic skills would be required to be able to practice religion in all its wholesomeness.Autism is a condition characterized by a lack of social communication and reciprocation skills.Research suggests that autistic individuals have difficulty understanding others' mental states and empathizing with them [36].Most religious systems usually involve concepts such as belief in supernatural agents and agency, some degree of understanding of others' mental states, as well as imagination and empathy, which would be required to practice those concepts.The various religious developmental theories also emphasize the importance of these concepts, such as anthropomorphism [54], theory of mind (ToM), and empathy [55], in developing religiosity.So, it would not be improbable to logically assume that autistic individuals might have subdued religiosity as compared to NT individuals owing to their decreased cognitive abilities.The following studies explored religiosity, spirituality, or related concepts in the context of cognitive abilities like mentalizing, empathizing, or imagination [14,29,31,32,44,45].

Reference
The first breakthrough study focusing on religiosity and autism in adolescents in the context of mentalization was published in 2012.Out of a group of studies, study 1 recruited young autistic individuals and found that they had a lower score on belief as compared to NT adolescents [29].This was a landmark study that inspired further research.The study was well-designed, using adaptations of validated tools for religiosity and mentalization, and included participants from various religious beliefs.The comparison group was well-matched for various demographic and social characteristics.However, the sample size was small, consisting of 11 autistic and 13 NT adolescents, with only one female in each group.Religiosity was assessed using a self-reported four-item measure, but the proposed predictors of religiosity, that is, autism quotient (AQ) and empathy, were parent-reported.Another noticeable limitation was that despite a small sample size, individual ages or age ranges of the sample were not provided, and the mean ages recorded were slightly different for both groups.Overall, the study concluded that IQ was not a predictor of religiosity, but mentalization (AQ and empathy) was.Since it has been proposed that gender might be related to religiosity [56], the probability of results being skewed from this small sample size with only one female cannot be excluded.
In 2016, researchers carried out work on young people with HFA [14], where they matched young autistic individuals with NT controls (N = 19 in each group; male-to-female ratio 15:4) in the age range of 12-31 years; however, associations were calculated after controlling for age, IQ, and religious upbringing.They assessed seven major domains of religiosity (adaptation of validated instruments, internally validated for research) and used various mentalizing methods like strange stories and false belief tasks to find the association between the two.Overall, there was no statistically significant difference between the two groups.Autistic adolescents, however, did have a statistically significant lower attraction to prayer.He concluded that HFAs have sufficient cognitive abilities to think and communicate with God and that any cognitive impairment they may have has little effect on other aspects of their religiosity besides their attraction to prayer.
A similar study [29] was replicated five years later by other fellow researchers [45] who attempted to improve on the previous methodology.Study 5 out of a group of studies included 33 HFA adolescents and 29 NT controls, out of whom 28 and 17 were males, respectively.Not only were the data collected from the participants themselves, but a mix of various techniques, including self-reports and intentional videos such as geometric figure task (GFT), were used to measure the association between religiosity and mentalization.Additionally, the role of cultural factors in religiosity was assessed.The study concluded that the groups did not differ on religious behaviors, religiosity, or credibility-enhancing displays (CREDs) and that mentalizing difficulties could not be linked with disbelief.One significant limitation, though, was that the religiosity measure was not validated.The research highlighted the postulation that factors like CREDs of religiosity might play a bigger role in determining one's views and beliefs than innate cognitive features.
An interesting finding in a small sample size comparison study in a predominantly Catholic school found that the autistic adolescents scored almost the same as NT controls on factors like religious practices and perceptions of God, but their ability to attribute agency to supernatural beings decreased as they grew older [32].A mixed-methods study by Visuri, while studying the role of empathy as a part of mentalizing ability in the development of religious beliefs, found no statistically significant difference in empathy concern scores between autistic adolescents and NT controls [31].Yet another study concluded that autistic adolescents achieved significantly higher mean religious experience scores than their NT controls [48].
In three qualitative studies, HFA adolescents were interviewed, and they narrated their experiences regarding religion, faith, and their importance in their lives in their own words [44].In the second study [31], young autistic people expanded on various supernatural beliefs and faiths about bodiless agents.All participants affirmed having invisible companions.Most talked about being able to shift back and forth between the real world and imagination in the form of games, books, and daydreaming.It can be concluded that participants were imaginative and found the bodiless agents predictable and emotionally coherent contrary to the widespread belief that autistic individuals might perceive mental representations of superhuman agents as puzzling [31].In one interview, based on a Swedish background, most of the autistic adolescents confirmed experiencing supernatural experiences in somatosensory modalities [48].They seemed to use supernatural attributions as a coping strategy.Many ascribed this to invisible agents outside organized religion.This was an interesting finding that is in line with previous religious developmental theories, which postulate that religion is a social field and culture and society play a significant role in shaping it [57].This might explain how culture, occulture, and popular media can influence supernatural beliefs.The other available supernatural alternatives in popular media or culture may fill the gap left when there is a decline in religious stories with supernatural contexts in relatively secularized societies.
Findings from these studies clearly show that the cognitive ability of autistic adolescents, if not higher (as found in a few domains), is at least comparable to, or at the very least not too low, to affect their ability to understand or practice religious or supernatural concepts.However, all these studies have been done with a subset of autistic adolescents (HFA).Therefore, it might be justifiable to say that, in light of this review, religiosity (in terms of cognitive ability) might not be significantly subdued in a subset of autistic adolescents (HFA).However, the same statement might not be true for the autistic adolescent population as a whole, where only about half of them may have an average or above-average IQ [58].
These results are contrary to the findings in previous research that found a negative association between religiosity and autism [59]; however, the correlation was weak, and it was further explained that autistic symptoms would not necessarily point to atheism.Another study suggested that HFA individuals were more likely to identify as atheists and that AQ in atheists was higher than that in religious groups [36].That study collected data from internet religious forms as an online survey.The participants were not physiciandiagnosed, and the authenticity of the data was questionable.The results were in line with the findings from research that concluded that mentalization was either negatively related to or unrelated to religiosity in an NT college student sample [60].
The results do not defy the classical religious developmental theories that emphasize the importance of theory of mind (ToM), empathy [55], and anthropomorphism [54]; however, they propose that in HFA individuals, these abilities are not so compromised as to affect their ability to be religious; and minor deficiencies in these cognitive abilities would not significantly affect the ability of HFA adolescents to practice religiosity.
Most studies found no significant difference between autistic adolescents and NT adolescents in observable behaviors like service or congregational attendance, which require physical effort and social skills to some degree.A parent-report survey of children and adolescents with intellectual disabilities (IDs) and autism found no association between autism and spiritual practices [49].Two comparison studies found no difference in religious behavior [45] or religious practices [32] between autistic adolescents and control groups.
Out of two qualitative studies with participants from religious backgrounds, all participants in one study reported attending worship services weekly except one, who did so monthly [44], while the other reported that nearly half of the autistic adolescents attended some form of religious education/congregation [28].
One study, though finding no difference in the frequency of prayers between the two groups, did find a statistically significant difference in the "attraction to prayer" between the two groups [14].Greater attraction to prayer was associated, however, with lower deficits in social skills and could be linked to difficulties in social interaction in general.However, most of this research (4/6) was not controlled for religious affiliation or background.Two parent-reported surveys found fewer congregational activities in a mixed sample of autistic adolescents and ID [49] and a 50% decrease in religious service attendance in autistic adolescents [47].
Although most of the research shows no significant difference between autistic adolescents and NT adolescents regarding religious practices, the results need to be interpreted with caution, considering that most of the participants came from religious backgrounds.In the review itself, it was found that parental religious beliefs and activities were associated with the autistic youth's religious beliefs and practices [49], and parents who valued religion themselves attempted to share or transmit it to their children [28].These findings align with previous research, suggesting that parents, peers, and schools influenced religious service attendance in NT adolescents [61].
The study by Reddish et al. [14] was controlled for religious affiliation and did show a statistically significant difference in "attraction to prayer."The study by Lee et al. had the largest sample size (173 autism vs 23,768 controls) and the most widespread recruitment (50 US states) targeting adolescents specifically, so the results of a 50% decrease in religious service attendance are hard to ignore.Subjects were controlled for the absence of disabilities.The study did not target HFAs only, unlike most of the other studies [47].Therefore, stating that religiosity (in terms of religious behavior) was almost the same (HFAs) to somewhat mildly reserved (overall autism group) in autistic adolescents as compared to NT controls would be justifiable in light of this review.
The religious experience appeared as another prominent theme related to religiosity in autistic adolescents in this review.In a qualitative review [44], the adolescents reported that they viewed faith as a positive influence in their lives.In terms of sensory and supernatural religious and spiritual experiences, they scored higher on mean religious experience scores, as well as "felt presence of God" as compared to the control group [48].All described interactions with bodiless agents, most citing God as their invisible companion [31].They expressed their imaginative sides and said it was easier for them to interact with supernatural beings than humans.They expressed empathy.They admitted to having various somatosensory and spiritual experiences and being interested in supernatural beings outside of traditional organized religions.They used immersion in the imagination through stories, video games, and daydreaming as coping and problemsolving mechanisms [31,48].
In light of the findings, it can be concluded that autistic adolescents do not have a significantly reserved religiosity (religious and supernatural experience), but again, these findings represent one subset of autism only (HFA) and cannot be generalized to the whole group.So far, the current research is insufficient to answer this question for the whole group, as research in this domain is only carried out on HFA and those with verbal skills, due to the difficulties in expression experienced by nonverbal or below-average IQ individuals with autism.
This result was understandable from the point of view of religious developmental theories as well, which postulate that cognitive abilities about supernatural agents and agency are an important aspect of religious cognition [62].The HFA participants under discussion experienced a wide range of supernatural experiences and were found to have the same degree of religious experience as NT adolescents.Thus, looking at the concept of religiosity and spirituality as a whole, it can be inferred from the available research included in this review that religiosity (cognitive abilities, behaviors, and experiences) in a subset of adolescents with autism (HFA) might not be significantly reserved as compared to NT adolescents.However, there is not enough research to conclude the same, or indeed the opposite, for autistic adolescents in general.
The little research available on autistic individuals as a whole (and not exclusively on a subset of HFA individuals) is mainly based on observable behaviors, such as church, mass, or congregational attendance, possibly due to the methodological limitations of assessing other domains in individuals with intellectual or verbal deficits.The level of religiosity (based on religious attendance) was found to be lower in this population than the NT controls in one study [47].
Parent and caregiver interviews highlighted somewhat similar themes overall in qualitative interviews.The majority considered religious inclusion and participation beneficial and essential for their children and wanted them to know and learn their beliefs.They expected stakeholders like religious bodies, the government, and teachers to include and support them in achieving this.Only a few had negative experiences with the religious services, and some thought that either their children did not need them or they would not benefit from them.Similar ideas are being supported in upcoming research proposing that families with disabled children may find a path to full social inclusion through religious organizations [63].This aligns with Elkind's study of religious development, which postulates that institutions such as religion help individuals in society as they move through different phases of life to find solutions for various problems they encounter [64].
The review highlighted the possible relationship between quality of life (QoL), faith, and religiosity.Autism was associated with low faith and poor QoL.These findings are in line with previous findings suggesting that autistic individuals have a much lower QoL than NT individuals [65].
Identifying unique and relevant resources for this vulnerable and much-needed patient population is essential.Providing support in this area for families and their children could prove helpful and improve the QoL of these adolescents with disabilities.Research on autistic adults has shown that they not only have spiritual needs but also use religious and spiritual practices and that these elements are connected to several life-quality indicators [66].

Significance and implications
Autistic individuals and their caregivers regard religiosity and spirituality as important domains in both their and their children's lives.They want their children to be given opportunities to be a part of religious groups and look forward to the government, religious, and healthcare authorities actively supporting them in this area.The QoL of these adolescents is positively associated with their strength of faith.This can have implications for strategies to improve their QoL.Adolescence is a transitional time.It is a critical period of discovering oneself and deciding on actions that will probably affect one for the majority of one's adult life.
The decision to pursue a certain career, adopt a certain set of beliefs, or generally define one's values often comes at this time.This vital period of life, with its stresses combined with the burden of neurodiverse conditions like autism, multiplies the struggle.Any support, like religion/spirituality, that might serve as an additional resource for the adolescent and the family would be appreciated.
Looking at the multidimensional concept of religiosity, which encompasses the social, cultural, and personal domains, and its capability of engaging multiple disciplines in an individual's life, it seems to have a promising potential to be used as a resource for many, if not all, autistic adolescents.The findings call for policymakers, religious leaders, and healthcare professionals to devise strategies for inclusion and support for autistic adolescents.The possible role of religion as a resource and coping strategy for these children and their families is worth exploring.

Limitations
This review had a few limitations.All the included studies were cross-sectional.Some studies lacked methodological rigor and had biases such as small sample sizes and a lack of controls for possible confounding factors, such as IQ, gender, and religious affiliations.Most studies were not largely generalizable and mainly represented the Western world.Some studies were performed on a mixed population including adolescents and adults or children.Caution was taken to include the results from such pieces of research where either calculation was done after age was controlled or separate analyses were done for separate age ranges.Where this was not possible, the result was discussed, with the respective limitations mentioned.Most of the studies did not use adolescent-specific measures or tools for measuring religiosity or spirituality, accounting for relevant issues like age-appropriate language or parental religiosity.

Recommendations for further research
Since the study by Visuri [48] in 2020, no further significant research focusing on religiosity in autistic adolescents has been conducted.Research focusing on the comparison of a sample of autistic adolescents, with and without ID, with or without physical disability, and with NT controls can provide significant insight and bridge existing knowledge gaps.The use of validated, developmentally adapted measures to assess religiosity domains as well as advanced mentalizing measures and techniques like geometric figure videos and CRED scales while controlling for factors like age, gender, and religious affiliation might notably increase the validity of future research in this area.A better study design, like a longitudinal follow-up approach from childhood to adulthood, could be more insightful in understanding this developing and evolving phenomenon of religiosity in this population group.Further research on the impact of religiosity and spirituality on QoL, adjustment, and coping with disability for autistic adolescents and their families, using religion and spirituality as a resource, can prove to be a promising area.
Below is a summary of the most significant findings.
The ability to practice religion, owing to cognitive abilities such as mentalization and empathy, might be limited but not absent in the autistic adolescents under review, contrary to common beliefs.Being religious or spiritual might require a basic cognitive ability and some degree of theory of mind; however, this is neither fundamental nor the sole predictor of this multidimensional concept.Autistic adolescents had comparable empathy to their NT controls.HFA individuals were highly imaginative, and modern media and occulture played a significant role in shaping their supernatural beliefs and agency.HFAs found it more comfortable to communicate with supernatural agents, perhaps due to their coherent, controlled, and less complicated cognitive styles, perhaps without having to abide by NT social standards and norms.
Observable religiosity, such as religious attendance, was low compared to the NT adolescent sample in one large national survey.However, most of the studies suggested no significant difference between the two groups.Where religious attendance was found to be low in a large autistic adolescent sample compared to controls, the carer burden was high.This calls for investigating the role of carer burden as a possible limiting factor for religious service attendance.Greater attraction to prayer was associated with lower deficits in social skills and could be linked to struggles in social interaction in general.Culture and society played a prominent role in shaping religiosity and spirituality in these adolescents through CREDs of religiousness or atheism/secularism.Factors like religious background, affiliation, and the parents' or caregivers' strength of faith had a significant impact on the autistic adolescent's religiosity.
Most caregivers wanted their children to learn about religion and encourage spirituality, believing that it was important in their children's lives.The opinions of carers assume utmost significance in this context because, for teenagers, families will play the most active role in promoting religious and spiritual expressions until they move to adulthood.Reserved religiosity could be attributed to many factors, and decreased mental ability/mentalization, empathy, or imagination did not seem to be the primary predictors or contributors to the development of religiosity in this population.The role of culture, parents, caregivers, and religious affiliations was significant.It might prove to be a stronger contributor to religiosity and its expression than other previously argued predictors like mentalization.QoL was positively associated with faith in autistic adolescents.

FIGURE 1 :
FIGURE 1: PRISMA flow diagram PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analyses; EBSCO: Elton B. Stephens Company photographic lifestory interview was designed for the study, assigning the participants the role of the expert, preparing their interviews by taking photos of aspects

Table 1
displays search results and search strings.
Search strings S1 autis* OR Asperger* OR "pervasive developmental" OR Kanner* OR "high functioning autism" S2 religio* OR spiritual* OR faith OR secular* OR atheis* OR Religious experience OR "religious belief" OR "belief system" OR "religious cognition" OR prayer S3 adolescen* OR teenager* OR young adults OR teen* OR youth OR young people

TABLE 1 : APA PsycInfo, APA PsycArticles, and APA PsycTests search results
APA PsycInfo: 35; APA PsycArticles: 2; no duplicates This yielded 68 articles for further screening, as shown in Table2.Search stringsS1 autis* OR Asperger* OR "pervasive developmental" OR Kanner* OR "high functioning autism"S2religio* OR spiritual* OR faith OR secular* OR atheis* OR Religious experience OR "religious belief" OR "belief system" OR "religious cognition"

TABLE 6 : The narrative matrix for the synthesis of quantitative studies
CRED: cognitive reflection and epistemic development; GFT: geometric figures task; AQ: autism quotient; IQ: intelligence quotient; TD: typically developing; HFA: high-functioning autism; ID: intellectual disability; NSCH: national survey of children's health; ADHD: attention deficit hyperactivity disorder; ASD: autism spectrum disorder; NT: neurotypical; EToM: existential theory of mind; AS: autism spectrum; IRI: interpersonal reactivity index; SPRED: specialized program for children with autism