Health Services Utilization Among Children With and Without Autism Spectrum Disorders

Adverse Childhood Experiences and Health Outcomes Among Transition-Age Autistic Youth

BACKGROUND

Adverse childhood experiences (ACEs) have been associated with poor health outcomes in the general population. However, their impact on autistic youth remains unclear.

OBJECTIVE

The primary objective was to understand how childhood adversity is related to the general health, mental health, and physical health of transition-age autistic youth.

PARTICIPANTS AND SETTING

Using data from the 2018-2021 National Survey of Children's Health, this cross-sectional study involved 2056 autistic youth aged 12-17.

METHODS

Logistic regression was employed to test the association between three measures of ACEs - individual ACEs, cumulative ACEs, and grouped ACEs based on contexts, and health outcomes of autistic youth.

RESULTS

Our study observed a high prevalence of ACEs among autistic youth, with a substantially higher proportion experiencing multiple ACEs than their neurotypical peers. Individual ACEs were significantly associated with specific health issues. Cumulative ACEs demonstrated a clear dose-response relationship with health outcomes, with higher ACE counts increasing the likelihood of experiencing poor general health, mental health conditions, and physical health issues. Moreover, grouped ACEs associated with health differently, with community-based ACEs being particularly linked to general health status, mental health conditions, and physical health conditions, while family-based ACEs correlated more with more severe mental health conditions and being overweight.

CONCLUSION

These findings collectively emphasize the importance of addressing ACEs as a public health concern among transition-age autistic youth, highlighting the need for targeted interventions, prevention strategies, and support services to mitigate the negative impact of ACEs on the overall well-being of this growing community.

The Development and Acceptability of a Comprehensive Crisis Prevention Program for Implementation in Health Care Settings

INTRODUCTION

Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises.

AIMS

We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs.

METHOD

Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees.

RESULTS

Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time.

CONCLUSION

The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations.

The impact of COVID-19 on receipt of health services among children with and without autism

ABSTRACT

TThe COVID-19 pandemic disrupted a range of health services for children across the United States. Autistic children have well-documented deficits in health-related services compared to nonautistic children. Parents of autistic children reported an increase in mental health and behavior problems with the onset of the pandemic, increasing the need for supportive services. The current study used data from the National Survey of Children’s Health from 2019 and 2020 to conduct logistic regressions predicting the likelihood of having unmet service needs before and after the onset of the pandemic. Results suggested that autistic children were more likely to have unmet medical, dental, and mental health service needs across years compared to nonautistic children, but there were no interactions by year. All children experienced an increased likelihood of having unmet needs from pre- to post-pandemic. Results suggest that although the pandemic disrupted services across the board, autistic children lacked health services regardless of the pandemic, pointing to persisting disparities in service receipt. A discussion of ongoing barriers to services and issues related to virtual services is included. Future research should further investigate the feasibility of virtual services as well as ways of reducing barriers to all services for autistic children.

Appropriateness of psychopharmacological therapies to psychiatric diagnoses in persons with autism spectrum disorder with or without intellectual disabilities: a cross-sectional analytic study

BACKGROUND

Observational studies highlighted high rates of psychotropic medication in persons with autistic spectrum disorder (ASD) with or without intellectual disability, which seems to be associated with the management of problem behaviors more than co-occurrent psychiatric disorders. The purpose of the study is to investigate psychopharmacology use and diagnoses of co-occurrent psychiatric disorder (PD) in persons with ASD attending a public mental health service in Emilia Romagna, Italy.

METHODS

The present study is a multicenter, cross-sectional study.

RESULTS

275 persons out of 486 (56.5%) resulted to receive at least one psychotropic drug, compared to 74 persons (15.2%) that were diagnosed with a PD. 63.6% were on poly-pharmacotherapy (2-10 compounds), with 37.8% receiving 3 or more medications. Antipsychotics were the most frequently prescribed class of psychotropic drugs (89%), followed by antiepileptics/mood stabilizers/lithium (42.1%) and anxiolytics (BDZ) (38.5%). Most common psychiatric disorders were psychotic disorders (29.7%), followed by anxiety disorders (17.5%), bipolar disorders (12.2%), and depressive disorders (9.4%).

CONCLUSIONS

Our findings support earlier research showing that many individuals with ASD receive pharmacotherapy without being diagnosed with a co-occurring psychiatric disorder, indicating that the main reasons for prescription and the type of compound frequently have little to no link with specific psychopathology.

Neurodivergence and radiology: How medical professionals can optimise the standard of care provided to autistic paediatric patients

INTRODUCTION

Several studies have been published regarding patients with various neurodevelopmental diagnoses attending hospital appointments, however, few focus on autism and the radiology department. This paper aims to identify how implementing patient-centred strategies and protocols for autistic paediatric patients will benefit the patient pathway and provide a more comfortable experience for those undergoing different scans and procedures within the radiology department.

METHODS

Using several electronic databases, articles were collected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and analysed with the Critical Appraisals Skills Programme (CASP).

DISCUSSION

A total of 8 articles are discussed and analysed in this review, focussing specifically on patient-centred procedures and practice, costs of healthcare services and how multidisciplinary teamwork compares to applied behavioural analysis.

RESULTS

The articles concluded that the current practice of multidisciplinary working is the most beneficial for patients. Furthermore, implementing autism awareness programmes and patient-specific protocols will help reduce anxiety surrounding scans within the radiology department.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Implementing mandatory autism awareness programmes and continuing with the multidisciplinary approach for autistic paediatric patients would provide the best possible patient-centred care.

The impact of autism spectrum disorder on parent employment: Results from the r-Kids study

Parents of children with autism spectrum disorder (ASD) and other chronic health conditions often face exceptional caregiving demands that can lead to challenges related to maintaining and succeeding in employment. Detailed information on the specific ways in which these health conditions impact parent employment could aid in designing equitable, effective policies to support families. The r-Kids study used electronic health records to identify three groups of children: those with ASD, asthma, or neither condition (control), from several health care systems. We oversampled racial and ethnic minorities and matched the asthma and control groups to the age and sex distribution of the ASD group. Parents completed three online surveys over the course of a year to measure annual employment outcomes. Surveys included the Family Economic Impact Inventory (measuring employment impacts) and measures of quality of life and symptom severity. All materials were provided in English and Spanish. The study enrolled 1461 families (564 ASD, 468 asthma, 429 control). Youth were 3-16.5 years old and predominantly male (79%). The sample was diverse (43% non-Hispanic White; 35% non-Hispanic Asian, Black, Native Hawaiian, or Other; and 21% Hispanic ethnicity). Parents of children with ASD were significantly less likely to be employed than parents of youth with asthma and control combined (OR: 14.2, p < 0.001), and were more likely to have other difficulties with employment and productivity while at work. Public and employer policies to help mitigate these impacts could aid families in managing care for youth with ASD.

A cross-sectional examination of service complexity in youths with co-occurring autism spectrum disorder and psychiatric or medical diagnoses across service sectors

Introduction

Autism spectrum disorder (ASD) is a heterogeneous, life-long, and complex condition. Youth diagnosed with ASD require several supports addressing core symptoms associated with the disorder, but also those resulting from co-occurring mental and physical health conditions. As a result, their care is overseen by numerous professionals spanning various service sectors, but communication between sectors is hindered due to the absence of a standardized assessment system to identify and triage youth to services. A paucity of information surrounding this population's service use lingers and a siloed delivery system persists.

Methods

Using archival data collected from 1,020 youth between 12 and 18 years of age, this study explored service complexity among autistic youth with and without psychiatric and medical co-occurring conditions in Ontario, Canada. In doing so, a negative binomial regression was utilized to investigate which predisposing, enabling, and need variables were associated with service complexity.

Results

Results revealed that experiencing financial difficulties was not associated with service complexity. However, age, sex, caregiver distress, comorbidity, intellectual disability, and evaluated health status were significant predictors. More specifically, female youth and youth with distressed caregivers had greater mental health service complexity scores. Additionally, youth diagnosed with two or more conditions in addition to ASD who required longer durations of programming, controlling for other predictors, had greater mental health service complexity scores. Yet, youth with an intellectual disability had lower service complexity scores.

Discussion

Clinical implications of this study are discussed to inform future investments into mental health efforts for autistic youth.

Identifying Components of Autism Friendly Health Care: An Exploratory Study Using a Modified Delphi Method

OBJECTIVES

Autistic individuals report lower health care satisfaction. However, there is currently no set of "best practice" standards about caring for autistic individuals. In this exploratory study, we aim to identify features of Autism Friendly practice according to a sample consisting of mainly professionals whose interests include autism using a modified 3-round Delphi-a method that identifies a consensus view across subject participants.

METHODS

Statements about components of an Autism Friendly health care practice were compiled in consultation with the steering committee of an Autism Friendly Initiative at a single, urban academic safety-net hospital. Participants were recruited through our national network of professionals and patients/families mailing list. Examples of invited professionals included researchers, health care workers, and educators. In the first 2 rounds, we distributed electronic surveys to participants, who scored statements from 1 to 9 regarding importance. In round 2, statements that were scored low by all stakeholder groups were eliminated. Seventy-eight participants responded to the first-round survey, and 51 participants responded to the second-round survey. In the third round, 38 participants ranked 16 statements from most to least important. Statements are summarized and presented in the Results section.

RESULTS

Topics that emerged from highly ranked statements include environmental/operational modifications (e.g., longer appointment times) and staff training to support autistic patients.

CONCLUSION

Highly ranked statements represented previously reported barriers, including the need for staff training and inclusive engagement with the autistic community. The findings can help inform health care organizations to determine priorities when building an Autism Friendly health care practice.

Hospitalizations Among Children and Youth With Autism in the United States: Frequency, Characteristics, and Costs

National estimates of hospitalization diagnoses and costs were determined using the 2016 HCUP Kids' Inpatient Database. Children and youth with autism were hospitalized over 45,000 times at over $560 million in costs and 260,000 inpatient days. The most frequent principal diagnoses for hospitalizations of children and youth with autism were epilepsy, mental health conditions, pneumonia, asthma, and gastrointestinal disorders, which resulted in almost $200 million in costs and 150,000 inpatient days. Mental health diagnoses accounted for 24.8% of hospitalizations, an estimated $82 million in costs, and approximately 94,000 inpatient days. Children and youth with autism were more likely hospitalized for epilepsy, mental health diagnoses, and gastrointestinal disorders, and less likely for pneumonia and asthma compared to other children and youth.

Association Between In-Home Treatment and Engagement in Psychosocial Services Among Medicaid-Enrolled Youth

OBJECTIVE

Prior studies have identified low rates of engagement in mental health (MH) services in clinic settings among children enrolled in Medicaid. Yet, little is known about whether the delivery of in-home MH treatment (in which the clinician travels to the child's home) improves engagement for this population. This study examines the association between the delivery of in-home psychosocial treatment and engagement in services among Medicaid-enrolled youth.

METHOD

We used 2010 to 2014 Georgia Medicaid claims data to identify 53,508 children and adolescents (aged 5-17 years) with a MH diagnosis that initiated new psychosocial treatment. We estimated regression models controlling for covariates to examine the relationship of the receipt of any in-home psychosocial treatment in the home setting with 3 outcome measures of engagement: receipt of at least 4 psychosocial visits during the first 12 weeks; total number of psychosocial visits during the first 12 weeks; and total duration of service use.

RESULTS

Those who received any in-home psychosocial treatment (compared to those who did not) had 4.3 times the odds (odds ratio = 4.3, 95% CI = 4.0, 4.7) of receiving at least 4 visits during the first 12 weeks, had 4.5 (95% CI = 4.3, 4.7) more predicted visits during the first 12 weeks, and had a longer treatment episode duration (mean rate ratio = 1.54, 95% CI = 1.48,1.59).

CONCLUSION

Although many Medicaid-enrolled youth do not receive a sufficient number of MH services to achieve positive outcomes, our findings suggest that providing in-home psychosocial treatment can improve service engagement and potentially help address this challenge.

Heterogeneity in Autism Spectrum Disorder Case-Finding Algorithms in United States Health Administrative Database Analyses

Strengthening systems of care to meet the needs of individuals with autism spectrum disorder (ASD) is of growing importance. Administrative data provide advantages for research and planning purposes, including large sample sizes and the ability to identify enrollment in insurance coverage and service utilization of individuals with ASD. Researchers have employed varying strategies to identify individuals with ASD in administrative data. Differences in these strategies can limit the comparability of results across studies. This review describes implications of the varying strategies that have been employed to identify individuals with ASD in US claims databases, with consideration of the strengths and limitations of each approach.

Brief Report: Telehealth Satisfaction Among Caregivers of Pediatric and Adult Psychology and Psychiatry Patients with Intellectual and Developmental Disability in the Wake of Covid-19

Telehealth has been shown to be both acceptable and effective in many areas of healthcare, yet it was not widely adopted prior to the SARS-CoV-2 (COVID-19) pandemic. Additionally, previous evaluations of telehealth for autism spectrum condition (ASC) and intellectual and developmental disability (IDD) populations are limited in both number and scope. Here, we investigated satisfaction amongst Psychology and Psychiatry patient caregivers at Cincinnati Children’s Hospital Medical Center (CCHMC) after the onset of the COVID-19 pandemic. Results (640 responses) showed high rates of satisfaction across departments, appointment types, and diagnoses, with 92% indicating overall satisfaction with their appointment. There were, however, notable decreases in satisfaction among Group Therapy respondents, and those whose diagnosis was classified as Other.

Contributing factors to healthcare costs in individuals with autism spectrum disorder: a systematic review

BACKGROUND

Individuals with autism spectrum disorder (ASD) are more likely to use healthcare than their counterparts without disabilities, which imposes high medical costs to families and health systems. This study aimed to investigate healthcare costs and its determinants among individuals with ASD.

METHODS

In this systematic review, we searched online databases (Web of Science, Medline through PubMed and Scopus) for observational and experimental studies that included data on service use and costs associated with ASD and published between January 2000 and May 2021. Exclusion criteria included non-English language articles, duplicates, abstracts, qualitative studies, gray literature, and non-original papers (e.g., letters to editors, editorials, reviews, etc.).

RESULTS

Our searches yielded 4015 articles screened according to PRISMA guidelines. Of 4015 studies identified, 37 articles from 10 countries were eligible for final inclusion. Therapeutic interventions, outpatient visits and medications constituted the largest proportion of direct medical expenditure on individuals with ASD. Included studies suggest lack of health insurance, having associated morbidities, more severe symptoms, younger age groups and lower socioeconomic status (SES) are associated with higher medical expenditure in individuals with ASD.

CONCLUSIONS

This systematic review identified a range of factors, including lower SES and lack of health insurance, which are associated with higher healthcare costs in people with ASD. Our study supports the formulation of policy options to reduce financial risks in families of individuals with ASD in countries which do not have a tax-based or universal health coverage system.

Transition to Adulthood for Autistic Adolescents: Topics Discussed by Healthcare Providers With Autistic Patients and Families

PURPOSE

We surveyed healthcare providers to determine the extent to which they discuss transition-to-adulthood topics with autistic patients without intellectual disabilities.

METHODS

Seventy-four healthcare providers in the Philadelphia area reported on the patient age at which they begin transition conversations, topics covered, and provider comfort. We calculated the proportion of providers who endorsed each transition topic, overall and by clinical setting.

RESULTS

Providers initiated transition-related conversations at a median age of 16 years (IQR: 14, 18), with over half reporting they were "somewhat" or "a little" comfortable with discussions. Nearly all providers discussed at least one healthcare, well-being, and mental health topic, while basic need-related discussions were limited.

DISCUSSION

Results suggest providers may delay and feel poorly prepared to provide anticipatory guidance to autistic patients for transition to adulthood. Future efforts to enhance the available resources and preparation available to providers are essential to meet autistic patients' needs.

The Autism Intervention Research Network on Physical Health (AIR-P) Research Agenda

OBJECTIVES

In the United States, autistic individuals experience disproportionate physical and mental health challenges relative to non-autistic individuals, including higher rates of co-occurring and chronic conditions and lower physical, social, and psychological health-related quality of life. The Autism Intervention Research Network on Physical Health (AIR-P) is an interdisciplinary, multicenter research network for scientific collaboration and infrastructure that aims to increase the life expectancy and quality of life for autistic individuals, with a focus on underserved or vulnerable populations. The current paper describes the development of the AIR-P Research Agenda.

METHODS

Development of the research agenda involved an iterative and collaborative process between the AIR-P Advisory Board, Steering Committee, and Autistic Researcher Review Board. The methodology consisted of 3 phases: (1) ideation and design, (2) literature review and synthesis; and (3) network engagement.

RESULTS

Six core research priorities related to the health of autistic individuals were identified: (1) primary care services and quality, (2) community-based lifestyle interventions, (3) health systems and services, (4) gender, sexuality, and reproductive health, (5) neurology, and (6) genetics. Specific topics within each of these priorities were identified. Four cross-cutting research priorities were also identified: (1) neurodiversity-oriented care, (2) facilitating developmental transitions, (3) methodologically rigorous intervention studies, and (4) addressing health disparities.

CONCLUSIONS

The AIR-P Research Agenda represents an important step forward for enacting large-scale health-promotion efforts for autistic individuals across the lifespan. This agenda will catalyze autism research in historically underrepresented topic areas while adopting a neurodiversity-oriented approach to health-promotion.

Screening for Hypertension in Children With and Without Autism Spectrum Disorder

This cross-sectional study compares the frequency of hypertension screening at health maintenance visits between children with and without autism.

The creation of a specializedmedical-dental clinic for adults with developmental disabilities in Montreal, Canada

Purpose

There is inadequate health care for patients with developmental disabilities (DD), due to a number of systemic issues. This case study describes the establishment of a medical-dental clinic in Montréal, Québec for adults with DD. The purpose of this paper is to describe the model of interdisciplinary care based on best practices, as an example to encourage a growing community of trained health professionals to serve this population.

Design/methodology/approach

Interviews with all the clinic staff and leadership were conducted on-site at the clinic, followed by document review and discussions with an embedded researcher in the organization.

Findings

The clinic was established through a series of events that led to public and government interest to act, the timely emergence of major donors, and bringing together several dedicated individuals and organizations. The core team engaged in consultation with clinics, followed by extensive billing analyses and iterative process mapping as a learning organization. Prior to patient visits, the clinic conducted detailed intake processes to adequately plan for each patient interaction. Desensitization visits were undertaken to improve patient tolerance for examination and treatment. The continual collection of data fed into an evaluation framework to facilitate continuous improvement and articulate a model for replication.

Originality/value

To the best of the authors knowledge, there is not a clinic of this nature serving this population in Canada. This work can serve to inform the efforts of other care providers looking to create a medical – dental home for this population.

Brief Report: The Experiences of Families of Children with an Autism Spectrum Disorder When Seeking Patient-and Family-Centered Care

Patient-and family-centered care (PFCC) is a partnership among healthcare professionals, patients, and families that is grounded in mutual respect and is an approach that impacts delivery of care, decision-making, and information sharing. PFCC should be implemented for all, including individuals with Autism Spectrum Disorders (ASD), who experience adverse medical encounters despite increased prevalence and healthcare utilization. Insights into the experiences of families during medical experiences can inform clinical practice by increasing healthcare professionals' understanding of the population. Using a mixed-methods approach, the perspectives of 40 families were analyzed. The themes include barriers and opportunities to improve upon the delivery of PFCC, which help to advance healthcare interactions and inform solution-based initiatives to facilitate medical visits that may benefit all patients.

Where are US outpatient mental health facilities that serve children with autism spectrum disorder? A national snapshot of geographic disparities

LAY ABSTRACT

There has been a rise in the observed prevalence of autism spectrum disorder among children. Existing studies show the share of counties with a treatment facility that offers care for children with autism spectrum disorder. However, no estimates exist of the share of US outpatient mental health treatment facilities that provide services for children with autism spectrum disorder. We identified key facility-level characteristics in offering mental health care for children with autism spectrum disorder. We used a telephone survey to contact almost all outpatient mental health treatment facilities in the contiguous United States. We asked the facilities if they provided mental health care for children with autism spectrum disorder. We took the results of this survey and estimated multivariable regressions to examine county- and facility-level predictors of offering services. We found that over half (50.3%) of the 6156 outpatient facilities reported offering care for children with autism spectrum disorder. Non-metro counties, counties with a lower percentage of non-White residents, counties with a higher percentage of uninsured residents, and counties with a higher poverty rate had fewer outpatient mental health treatment facilities providing care for children with autism spectrum disorder. Facilities accepting Medicaid as a form of payment, offering telehealth, and private for-profit facilities were more likely to provide services for children with autism spectrum disorder. Because only half of outpatient mental health treatment facilities offer care for children with autism spectrum disorder, public health officials and policymakers should do more to ensure that this vulnerable population has access to mental health services.

Autistic traits are associated with faster pace of aging: Evidence from the Dunedin study at age 45

Growing evidence indicates that the defining characteristics of autism spectrum disorder (ASD) are distributed throughout the general population; hence, understanding the correlates of aging in people with high autistic traits could shed light on ASD and aging. 915 members of the Dunedin longitudinal birth cohort completed a measure of autistic traits at age 45. A composite measure of the "pace of aging" was derived by tracking the decline in 19 biomarkers across ages 26, 32, 38, and 45 years. Facial age was also assessed. Reports of perceived health were collected from participants themselves, informants, and interviewers. Higher self-reported autistic traits significantly correlated with a faster pace of aging, older facial age, and poorer self-, informant-, and interviewer-rated health. After control for sex, SES and IQ, autistic traits were significantly associated with each variable: pace of aging (β = 0.09), facial age (β = 0.08), self- (β = -0.15), informant (β = -0.12), and interviewer-rated (β = -0.17) health. Autistic traits measured at age 45 are associated with faster aging. Participants with high autistic traits appear to be more vulnerable to poor health outcomes, as previously reported for those clinically diagnosed with ASD. Therefore, autistic traits may have important health implications. Replicating these findings in samples of autistic people is needed to identify the mechanism of their effect on aging and physical health to improve outcomes for those with ASD diagnoses or high autistic traits. LAY SUMMARY: The role that autistic traits have in relation to health outcomes has not been investigated. We looked at how physical health and aging (measured with self-reported questions and decline in multiple biological measures) were related to autistic traits (measured with a questionnaire, at age 45). We found that higher autistic traits were associated with poorer reports of physical health, and a faster pace of aging. This suggests that both those with autism and those with higher autistic traits may be more likely to experience poorer health outcomes.

Healthcare utilization among children with early autism diagnoses, children with other developmental delays and a comparison group

Aim: To describe healthcare utilization patterns among children with autism (n = 1821), and compare these patterns to children with other developmental delays (DD; n = 12,336) and a population comparison (PC; n = 18,210) cohort. Materials & methods: Retrospective study of administrative billing data. Results: Children with autism had roughly six-times more annual outpatient visits as PC children and twice as many as children with DD. Children with autism were more likely than PC children to use nearly all services, but comparisons between the autism and DD cohorts were mixed. Children with autism were more likely to have psychiatry/psychology visits, 'other' specialty care visits and psychotropic prescriptions, but less likely to have pediatric specialty care visits, immunizations and some prescriptions. Conclusion: Findings reveal opportunities to streamline, coordinate or improve care for young children with autism, particularly for outpatient services, and to give caregivers appropriate anticipatory guidance about what to expect after an autism diagnosis.

Systematic Review of Disparities and Differences in the Access and Use of Allied Health Services Amongst Children with Autism Spectrum Disorders

Individuals with autism spectrum disorder (ASD) often benefit from allied health services such as occupational therapy, speech and language pathology, and applied behavioral analysis. While there is consistent evidence of disparities in access and use of medical services (e.g. dentistry), no such systematic review has examined disparities and differences in allied health use amongst children with ASD. In this systematic review, we examine disparities and differences in service access and use for children with ASD. Our findings suggest that children who are older, have less severe ASD symptoms, are from minority groups, and those from particular geographic regions are less likely to receive allied health services. Limitations and future directions are discussed.

Generosity of state insurance mandates and growth in the workforce for autism spectrum disorder

LAY ABSTRACT

To improve access to health services for children with autism spectrum disorder, US states have passed laws requiring health insurers to cover autism-related care, commonly known as state insurance mandates. However, the features of mandates differ across states, with some state laws containing very generous provisions and others containing very restrictive provisions such as whether the mandates include children aged above 12 years, whether there is a limit on spending, and whether there are restrictions on the types of services covered. This study examined the relationship between generosity of mandates and growth in the health workforce between 2003 and 2017, a period during which 44 states passed mandates. We found that states that enacted more generous mandates experienced significantly more growth in board-certified behavioral analysts who provide behavioral therapy as well as more growth in child psychiatrists. We did not find differences in the growth of pediatricians, which is a less specialized segment of the workforce. Our findings were consistent across eight different mandate features and suggest that the content of legislation may be as important as whether or not legislation has been passed in terms of encouraging growth in the supply of services for children with autism spectrum disorder.

Brief Report: Analysis of Dental Treatment Provided Under General Anaesthesia for Children and Young Adults with Autistic Spectrum Disorder and Identification of Challenges for Dental Services

Dental treatment provided under general anaesthesia (DGA) is an expectation for many children and young adults (CYA) diagnosed with Autistic Spectrum Disorder (ASD). Planning and delivery of DGA requires consideration of morbidity and mortality risks and implications for families and healthcare services. One hundred patient records of CYA with special healthcare needs were analysed to examine characteristics and experience of DGA revealing that 79% of CYA had a diagnosis of ASD. Forty-seven percent of CYA diagnosed with ASD had at least one previous hospital admission for DGA. For 24% of this repeat DGA group, the previous DGA was within a two-year period. Results highlight a high rate of DGA and need to investigate more effective primary dental care strategies.

Shared Features or Co-occurrence? Evaluating Symptoms of Developmental Coordination Disorder in Children and Adolescents with Autism Spectrum Disorder

Motor differences are common in Autism Spectrum Disorder (ASD), but rarely evaluated against diagnostic criteria for Developmental Coordination Disorder (DCD). We aimed to determine whether motor problems in ASD represent the possible co-occurrence of DCD. We retrospectively reviewed standardized assessments and parent-reports to evaluate motor ability in 43 individuals with ASD against diagnostic criteria for DCD, and compared to 18 individuals with DCD. Over 97% of cases in the ASD group scored below the 16th percentile in motor ability, with most below the 5th percentile. Over 90% of cases in the ASD group met criteria for co-occurring DCD. Motor challenges are a clinically-significant problem in ASD; systematically assessing the prevalence of co-occurring ASD + DCD is necessary to optimize assessment and intervention.

Development and evaluation of a novel caregiver-report tool to assess barriers to physical healthcare for people on the autism spectrum

INTRODUCTION

People on the autism spectrum often experience poorer health than the general population despite higher engagement with the health services. This suggests a disparity in the accessibility of appropriate healthcare for autistic individuals. To improve access, barriers the autism community experience in healthcare first need to be identified. This paper aimed to: 1) develop and evaluate a caregiver-report tool; 2) identify barriers to physical healthcare for autistic individuals; and 3) identify potential contributing factors.

METHODS

A previously established taxonomy of barriers to healthcare for autistic individuals informed the development of the tool; this was then distributed to caregivers of autistic adults and children. Exploratory factor analysis (EFA) assessed validity and reliability of the tool. Multiple Regressions were performed to identify predictors of barriers.

RESULTS

In total, caregivers of 194 autistic children or adults participated in the study. The EFA produced four factors: 1) patient-level barriers; 2) healthcare provider-level (HCP) barriers; 3) healthcare system-level barriers; and 4) barriers related to managing healthcare. The greatest barriers included difficulties with identifying/reporting symptoms (endorsed by 62.4% of participants); difficulties handling the waiting area (60.3% of participants); and a lack of HCP knowledge regarding autism (52.1% of participants). Autism severity, general adjustment problems, anxiety, age and having unmet needs predicted the frequency and/or severity of barriers.

CONCLUSIONS

A tool that allows assessment of patient-, HCP-, and system-level barriers to healthcare was developed and evaluated. Patient-level barriers appear to occur frequently and pose substantial challenges. This tool will help identify areas most in need of intervention and support intervention evaluation.

Identifying Children and Youth With Autism Spectrum Disorder in Electronic Medical Records: Examining Health System Utilization and Comorbidities

Autism spectrum disorder (ASD) is a neurodevelopmental disorder requiring significant health and educational resources for affected individuals. A reference standard for ASD was generated from an existing population‐based cohort of 10,000 children and youth aged 1–24 years who were randomly selected for chart abstraction from 29,256 patients from 119 family physicians. We developed and validated an algorithm to identify children and youth with ASD within an electronic medical record system (N = 80,237, aged 1–24 years) in order to examine the prevalence of comorbidities and quantify health system utilization within the cohort. We identified 1,062 children and youth with ASD representing a prevalence of 1.32%. Compared to individuals without ASD, those with ASD had a higher prevalence of asthma, were more likely to visit a specialist, undergo surgery, and be hospitalized for psychiatric reasons. Children and youth with ASD in Ontario have complex health system needs, illustrated through a significant burden of comorbidities and increased health system utilization.

Lay Summary

Our paper generates population‐based estimates of health system use by children and youth with ASD, who have a higher burden of comorbidities than the general population. We developed a case‐finding algorithm and applied it in electronic medical records to create a cohort of children and youth with ASD, thereby generating an important resource to further study the health care needs of individuals with ASD.

Health system utilization before age 1 among children later diagnosed with autism or ADHD

Children with autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) have 2-3 times increased healthcare utilization and annual costs once diagnosed, but little is known about their utilization patterns early in life. Quantifying their early health system utilization could uncover condition-specific health trajectories to facilitate earlier detection and intervention. Patients born 10/1/2006-10/1/2016 with ≥ 2 well-child visits within the Duke University Health System before age 1 were grouped as ASD, ADHD, ASD + ADHD, or No Diagnosis using retrospective billing codes. An additional comparison group was defined by later upper respiratory infection diagnosis. Adjusted odds ratios (AOR) for hospital admissions, procedures, emergency department (ED) visits, and outpatient clinic encounters before age 1 were compared between groups via logistic regression models. Length of hospital encounters were compared between groups via Mann-Whitney U test. In total, 29,929 patients met study criteria (ASD N = 343; ADHD N = 1175; ASD + ADHD N = 140). ASD was associated with increased procedures (AOR = 1.5, p < 0.001), including intubation and ventilation (AOR = 2.4, p < 0.001); and outpatient specialty care, including physical therapy (AOR = 3.5, p < 0.001) and ophthalmology (AOR = 3.1, p < 0.001). ADHD was associated with increased procedures (AOR = 1.41, p < 0.001), including blood transfusion (AOR = 4.7, p < 0.001); hospital admission (AOR = 1.60, p < 0.001); and ED visits (AOR = 1.58, p < 0.001). Median length of stay was increased after birth in ASD (+ 6.5 h, p < 0.001) and ADHD (+ 3.8 h, p < 0.001), and after non-birth admission in ADHD (+ 1.1 d, p < 0.001) and ASD + ADHD (+ 2.4 d, p = 0.003). Each condition was associated with increased health system utilization and distinctive patterns of utilization before age 1. Recognizing these patterns may contribute to earlier detection and intervention.

Access to Dental Visits and Correlates of Preventive Dental Care in Children with Autism Spectrum Disorder

Dental care received by children in the Autism Speaks Autism Treatment Network (ATN) was compared to National Survey of Children's Health (NSCH) data for children without special healthcare needs and children with parent-reported ASD. Correlates of obtained preventive dental services were examined within the ATN sample. Participants included 375 families of children ages 4 to 17 enrolled in the ATN. ATN families reported levels of preventive dental care that were similar to, or exceeded, NSCH-reported care. However, disparities in obtained preventive dental services emerged within the ATN sample. Lower intellectual functioning was the most consistent correlate of reduced access to and completion of preventive dental care. Implications for developing system-wide supports and targeted interventions are discussed.

Service use by youth with autism within a system-driven implementation of evidence-based practices in children's mental health services

Public mental health systems play an important role in caring for youth with autism spectrum disorder. Like other dually diagnosed populations, youth with autism spectrum disorder may receive services in the context of evidence-based practice implementation efforts within public mental health systems. Little is known about service use patterns within the context of system-driven implementations efforts for this population. This case-control study examined mental health service patterns of 2537 youth with autism spectrum disorder compared to 2537 matched peers receiving care in the Los Angeles County Department of Mental Health, the largest public mental health department in the United States, within the context of a system-driven implementation of multiple evidence-based practices. Although not the primary target of this implementation effort, youth with autism spectrum disorder were served when they met criteria for the services based on their presenting mental health symptoms. Comparative analyses using administrative claims data were conducted to examine differences in mental health utilization patterns and clinical characteristics. Findings revealed significant differences in the volume and duration of mental health services as well as differences in the service type and evidence-based practice delivered between youth with and without autism spectrum disorder. Results provide direction targeting implementation efforts for youth with autism spectrum disorder within a public mental health system care reform.

Autism spectrum disorder/Takiwātanga: An Integrated Data Infrastructure-based approach to autism spectrum disorder research in New Zealand

New Zealand has few estimates of the prevalence of autism spectrum disorder and no national registry. The use of administrative data sources is expanding and could be useful in autism spectrum disorder research. However, the extent to which autism spectrum disorder can be captured in these data sources is unknown. In this study, we utilised three linked administrative health data sources from the Integrated Data Infrastructure to identify cases of autism spectrum disorder among New Zealand children and young people. We then investigated the extent to which a range of mental health, neurodevelopmental and related problems co-occur with autism spectrum disorder. In total, 9555 unique individuals aged 0–24 with autism spectrum disorder were identified. The identification rate for 8-year-olds was 1 in 102. Co-occurring mental health or related problems were noted in 68% of the autism spectrum disorder group. The most common co-occurring conditions were intellectual disability, disruptive behaviours and emotional problems. Although data from the Integrated Data Infrastructure may currently undercount cases of autism spectrum disorder, they could be useful for monitoring service and treatment-related trends, types of co-occurring conditions and for examining social outcomes. With further refinement, the Integrated Data Infrastructure could prove valuable for informing the national incidence and prevalence of autism spectrum disorder and the long-term effectiveness of clinical guidelines and interventions for this group.

Fewer Than Half Of US Mental Health Treatment Facilities Provide Services For Children With Autism Spectrum Disorder

Despite estimates of rising prevalence of children with autism spectrum disorder (ASD) in the US, there is little research on the availability of behavioral health care services for this vulnerable population. To fill the gap, we surveyed 8,184 mental health treatment facilities in the contiguous US. As of August 2019, 43.0 percent of facilities reported providing behavioral health care for children with ASD, and 36.6 percent were accepting such children as new patients. Only 12.7 percent reported having a clinician with specialized training, and 4.3 percent reported having a specialized treatment program. Multivariable regression results indicated that there was poorer access to specialized ASD care in rural and lower-income communities. New policies are needed to increase the availability of behavioral health care for children with ASD.

Objective Estimates of Direct-Medical Costs Among Persons Aged 3 to 38 Years With and Without Research-Defined Autism Spectrum Disorder Ascertained During Childhood: A Population-Based Birth-Cohort Study

OBJECTIVES

Accurate estimates of autism spectrum disorder (ASD)-associated medical costs are essential for predicting future care needs, allocating resources, identifying best practices, and modeling cost-effectiveness. Most existing studies have either employed subjective cost data or ascertained ASD using self-reported or International Classification of Diseases-coded diagnoses. Such ascertainment is especially problematic for identifying milder ASD among older individuals never diagnosed with ASD.

METHODS

This 1976 through 2000 population-based birth-cohort study was set in Olmsted County, Minnesota. ASD cases and age- and sex-matched unaffected controls were identified by applying uniform operational research criteria for ASD (using the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) after rigorous review of provider-linked medical and public, private, or home school records available for all members from birth to a maximum age of 21 years. Medical cost estimates for the 901 case-control pairs used line-item provider-linked billing data (including all payers) from 2003 through 2014 (ages 3-38 years). Outpatient pharmaceutical costs were unavailable. Temporal changes in diagnostic criteria, clinical practice, public awareness, and access were addressed by separating analyses into 5-year age group and 4-year calendar period cells. Unadjusted and adjusted (age and age plus co-occurring conditions) cost estimates were provided for cases, controls, and case-control differences. Additional factors (co-occurring conditions, percentage hospitalized, intellectual disability) were investigated using unadjusted descriptive analyses.

RESULTS

Cell sample sizes ranged from 93 to 402 for age groups 3 through 19 years and from 45 to 395 for age groups 20 through 38 years. Unadjusted, age-adjusted, and fully adjusted medical costs were significantly higher for cases versus controls in 100% of cells for age groups 3 through 19 years and in 50% (unadjusted), 38% (age adjusted), and 12% (fully adjusted) of cells for age groups 20 through 38 years.

CONCLUSIONS

These unique estimates can help inform the construction of cost-effectiveness models; decisions by payers, providers, and policy makers; and predictions of lifetime costs.

Sleep Disorders in Children and Adolescents with Autism Spectrum Disorder: Diagnosis, Epidemiology, and Management

Sleep problems are a common complaint in children/adolescents with autism spectrum disorder (ASD). Correctly diagnosing and treating sleep problems in individuals with ASD is key, as they can add to the psychosocial burden of the disorder and exacerbate associated symptoms, such as inattention or irritability. Here, we provide an overview of the epidemiology, diagnosis, and management of sleep problems/disorders in children and adolescents with ASD. This narrative review is mainly informed by a systematic search in PubMed and PsycInfo (last search: 10 October 2019) of available pertinent meta-analyses. We also searched for randomized controlled trials (RCTs) published after the search date of available meta-analyses. As for the epidemiology of sleep disorders in ASD, recent meta-analytic evidence shows a pooled prevalence of 13% (95% confidence interval [CI] 9-17) in the ASD population, compared with 3.7% in the general population. In terms of diagnosis of sleep disorders, it should be based on standardized criteria [e.g., the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or third edition of the International Classification of Sleep Disorders (ICSD)]; clinicians should bear in mind that the communication difficulties presented by individuals with ASD may make the diagnostic process more challenging. Regarding the treatment, a meta-analysis of behavioral interventions, including only three RCTs, found significant effects in terms of increase in total sleep time (24.41 min, 95% CI 5.71-43.11, P = 0.01), decrease in sleep-onset latency (- 18.31 min, 95% CI - 30.84 to - 5.77, P = 0.004), and a significant effect on sleep efficiency (5.59, 95% CI 0.87-10.31, P = 0.02), albeit the risk of bias of the included studies was rated "high" in relation to issues with the blinding. The bulk of the evidence for the pharmacological treatment is for melatonin, with a meta-analysis of five double-blind RCTs showing a large effect size, favoring melatonin, in sleep duration (44 min compared with placebo, Hedge's g 1.07 [95% CI 0.49-1.65]) and sleep-onset latency (39 min compared with placebo, Hedge's g - 2.46 [95% CI - 1.96 to - 2.98]). We conclude that additional RCTs are desperately needed to support the management of sleep disorders in ASD with an evidence-based, precision medicine approach.

Trends in smoking documentation rates in safety net clinics

OBJECTIVE

To assess the impact of provider incentive policy on smoking status documentation.

DATA SOURCES

Primary data were extracted from structured electronic medical records (EMRs) from 15 community health centers (CHCs).

STUDY DESIGN

This was an observational study of data from 2006 to 2013, assessing changes in documentation of smoking status over time.

DATA EXTRACTION METHODS

We extracted structured EMR data for patients age 18 and older with at least one primary care visit.

PRINCIPAL FINDINGS

Rates of documented smoking status rose from 30 percent in 2006 to 90 percent in 2013; the largest increase occurred from 2011 to 2012 following policy changes (21.3% [95% CI, 8.2%, 34.4%] from the overall trend). Rates varied by clinic and across patient subgroups.

CONCLUSIONS

Documentation of smoking status improved markedly after introduction of new federal standards. Further improvement in documentation is still needed, especially for males, nonwhite patients, those using opioids, and HIV + patients. More research is needed to study whether changes in documentation lead to improvements in counseling, cessation, and patient outcomes.

Working with Children with Autism Spectrum Disorder in a Medical Setting: Insights from Certified Child Life Specialists

This study aimed to gain an understanding of Certified Child Life Specialists' (CCLS) experiences with and suggestions for working with children with autism spectrum disorder (ASD) in a medical setting. Using a mixed-method design, 118 CCLS completed an online survey and 16 participated in follow-up interviews. Participants believed many medical professionals, including CCLS, are not adequately prepared to work with children with ASD, negatively impacting quality of care. Participants emphasized that outcomes are best for children with ASD when parents and medical staff collaborate to meet the unique needs of each child. CCLS reported working with children with ASD can provide insights for enhancing the quality of care for all children. Participants' suggestions for training and resource development are discussed.

Healthcare access and services use among US children with autism spectrum disorder

This study aimed to determine associations of healthcare access problems with services use among US children with autism spectrum disorder. We analyzed 2011-2014 National Health Interview Survey data on 651 children with autism spectrum disorder aged 2-17 years. There were three measures of healthcare access problems: (1) delays accessing healthcare, (2) difficulty affording healthcare, and (3) trouble finding a primary care provider. There were five service use measures: (1) ⩾4 office visits, (2) ⩾1 well-child visit, (3) flu vaccine, (4) prescription medication, and (5) ⩾1 emergency department visit. Multivariable regression models estimated associations of ⩾1 healthcare access problem with each service use variable and effect modification by socioeconomic status and race and ethnicity. Twenty-nine percent of children with autism spectrum disorder had ⩾1 healthcare access problem. Having ⩾1 healthcare access problem was associated with lower adjusted odds of ⩾1 well-child visit or prescription medication use but higher adjusted odds of ⩾4 office visits or ⩾1 emergency department visit. No significant association was found for flu vaccine. Associations of healthcare access problems with emergency department use were most pronounced for higher socioeconomic status and White, non-Hispanic subgroups. Intervention, such as insurance expansion, is needed to improve healthcare access for children with autism spectrum disorder.

Prevalence of Co-occurring Medical and Behavioral Conditions/Symptoms Among 4- and 8-Year-Old Children with Autism Spectrum Disorder in Selected Areas of the United States in 2010

We compared the prevalence of various medical and behavioral co-occurring conditions/symptoms between 4- and 8-year-olds with autism spectrum disorder (ASD) from five sites in the Autism and Developmental Disabilities Monitoring Network during the 2010 survey year, accounting for sociodemographic differences. Over 95% of children had at least one co-occurring condition/symptom. Overall, the prevalence was higher in 8- than 4-year-olds for 67% of co-occurring conditions/symptoms examined. Further, our data suggested that co-occurring conditions/symptoms increased or decreased the age at which children were first evaluated for ASD. Similarly, among the 8-year-olds, the prevalence of most co-occurring conditions/symptoms was higher in children with a previous ASD diagnosis documented in their records. These findings are informative for understanding and screening co-occurring conditions/symptoms in ASD.

Vaccination in people with disability: a review

People with disabilities are vulnerable to complications from vaccine-preventable diseases, and every effort should be made to ensure equitable access to immunization for this population. This paper aims to summarize the research on immunizations in people with disabilities, in order to ensure a comprehensive understanding of knowledge in this area and direct further research. The literature is weighted towards coverage data that is difficult to synthesize because of the different definitions of disability, and the variety of settings, vaccinations and age groups across the studies. In-depth qualitative data and data from a variety of health-care providers and people with disability is notably lacking. This is vital to redress in order to develop effective immunization interventions in this population.

Emergency department utilization and monetary charges in adolescents with autism spectrum disorder, intellectual disability, and a population comparison group

Adolescents with autism spectrum disorder (ASD) and/or intellectual disability (ID) may utilize the emergency department (ED) more frequently than individuals in the general population. This study compared ED utilization and charges during adolescence among four groups of individuals: ASD-only, ASD + ID, ID-only, and a population comparison (PC) group. ED visits occurring during age 12-17 years were examined to identify non, low, and high utilizers. Logistic regression was used to compare groups on the odds of having at least one ED visit during adolescence. Generalized linear models were used to compare groups on number of ED visits and total charges, stratified by low and high ED utilization. Descriptive examination of presenting diagnoses was performed. Individuals with ID, with or without co-occurring ASD, were significantly more likely to have at least one ED visit during adolescence. Among high ED utilizers, the ID-only group had the most frequent ED visits but had significantly lower charges than the ASD-only group. Individuals with ASD-only and ASD + ID differed from the ID-only and PC groups in presenting diagnoses. No differences between groups in number of ED visits or charges were observed among low utilizers. ID, with or without ASD, increased the odds of visiting the ED during adolescence. Adolescents with ID-only had the most frequent ED visits, but individuals with ASD-only had the highest ED charges and tended to be seen for psychiatric concerns. Further research is warranted to better characterize and meet the healthcare needs of individuals with ASD and/or ID during adolescence. Autism Res 2019, 12: 1129-1138. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Frequent emergency department (ED) visits strain medical resources and are costlier than primary and urgent care. Our findings show that adolescents with intellectual disability (ID) may use the ED frequently for nonurgent conditions. Adolescents with autism spectrum disorder, without ID, use the ED less frequently but incur higher charges. Further research is needed to understand how to meet the unique needs of these populations in primary care to prevent overuse of the ED.

Child and Family Characteristics that Predict Autism Spectrum Disorder Specialty Clinic Appointment Attendance and Alignment with Providers

We examined factors contributing to initial appointment attendance, alignment between parents' pre-visit and clinicians' diagnostic impressions, and family commitment to follow-ups at an autism spectrum disorder (ASD) specialty clinic. Sample sizes were n = 6558 (initial), n = 1430 (alignment), and n = 1353 (follow-up). Parents completed surveys and clinicians provided their ASD diagnostic impressions. When children were not receiving intervention, families were less likely to keep their initial appointment. Families residing long distances and having older children were less likely to keep their initial and follow-up appointments. African American families were less likely to keep their initial appointment and expressed initial doubts with providers about the diagnosis. Findings suggest that some children are not getting diagnostic clarity or accessing timely services.

Medical Encounters for Youth With Autism Spectrum Disorder: A Comprehensive Review of Environmental Considerations and Interventions

Approximately 1 in 59 youth are currently diagnosed with autism spectrum disorder (ASD), a neurodevelopmental disorder. In comparison to typically developing peers, youth with ASD encounter hospitalization at higher rates due to their heightened health care needs. While visiting the hospital is a stressor for youth with neurotypical needs, the experience contains unique challenges for those with ASD. This systematic literature review highlights research that considers the psychosocial impact of the hospital environment on the coping and adjustment of youth with ASD. Specifically, the review focuses on recommendations and interventions that may be used by health care professionals while supporting this population as they encounter the health care system. Ninety-six articles were identified as meeting inclusion and exclusion criteria. The findings suggest that practicing clinicians should implement a wide variety of interventions for youth with ASD including diversion techniques, comfort positions, and picture schedules. Although there are published evidence-based interventions for supporting youth with ASD in the hospital, most clinicians lack ASD-specific training. This article concludes with recommendations for future research.

Use, costs, and predictors of psychiatric healthcare services following an autism spectrum diagnosis: Population-based cohort study

A number of cross-sectional studies report extensive use of psychiatric services and high healthcare costs in autistic youths. However, little is known about how the use of these services evolves from the time of diagnosis, as children grow up. Our objectives were to investigate the use, costs, and predictors of psychiatric services following autism spectrum diagnosis. We built a cohort of 1227 newly diagnosed autism spectrum individuals identified in the Quebec (Canada) Régie de l'assurance maladie du Québec administrative database (January 1998 to December 2010). Mean number and cost per individual of psychiatric healthcare use (hospitalizations, medical visits, psychoactive drug use) were calculated yearly for 5 years following autism spectrum diagnosis. Mean number of psychiatric visits decreased over time by more than threefold (7.5 vs 2.1 visits) from year 1 to year 5, whereas psychoactive drug use increased from 16.0 to 25.2 claims. Psychiatric hospitalizations decreased during follow-up, but still represented the greatest costs per individual (CAD9820 for year 1; CAD4628 for year 5). Antipsychotics represented over 50% of drug costs. Mixed-effect model with repeated measures showed that previous psychoactive drug use was the strongest predictor of greater psychiatric healthcare cost during follow-up (odds ratio: 9.96; 95% confidence interval: 7.58-13.10). These trends contrast with guidelines advocating cautious prescribing of antipsychotics with periodical re-assessment of their benefit.

Health Concerns and Health Service Utilization in a Population Cohort of Young Adults with Autism Spectrum Disorder

Individuals with autism spectrum disorder (ASD) have many health needs that place demands on the health service sector. This study used administrative data to compare health profiles in young adults 18–24 years of age with ASD to peers with and without other developmental disability. Young adults with ASD were more likely to have almost all the examined clinical health issues and health service use indicators compared to peers without developmental disability. They were more likely to have at least one psychiatric diagnosis, and visit the family physician, pediatrician, psychiatrist, and emergency department for psychiatric reasons, compared to peers with other developmental disability. Planning for the mental health care of transition age adults with ASD is an important priority for health policy.

Health Care Service Utilization and Cost Among Adults with Autism Spectrum Disorders in a U.S. Integrated Health Care System

Objectives

To compare health care utilization patterns and cost among insured adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls).

Method

We conducted a case-control study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) for at least 9 months each year from 2008 to 2012. Cases (N = 1507) were adults with an ASD diagnosis (ICD-9-CM 299.0-299.8) recorded in the electronic medical record on at least two separate occasions by December 31, 2012. Two control groups, adults with ADHD (N = 9042) defined by ICD-9-CM code 314 and GP (N = 15,070), were randomly selected and frequency matched to cases on gender and age. Health care utilization and cost data were obtained from KPNC databases for the year 2012.

Results

Compared with adults with ADHD, adults with ASD had significantly higher utilization of outpatient visits for primary care (74.2% vs. 66.6%), mental health (43.3% vs. 33.2%), and laboratory services (60.9% vs. 54.4%). Hospitalizations for ambulatory care sensitive diagnoses (5.4% vs. 2.3%) were less frequent overall but more common among adults with ASD than with ADHD. Group differences were larger comparing adults with ASD with GP controls. Gynecology visits and screening for cervical cancer were significantly less common among women with ASD than among women with ADHD (35% vs. 50%) or GP (35% vs. 49%). Total annual mean healthcare costs for adults with ASD were 20% higher than costs for adults with ADHD and double costs for GP.

Conclusion

Adults with ASD had significantly higher rates of utilization across most health care service areas compared with adults with ADHD or GP; however, women with ASD were significantly less likely to have gynecology visits and have screening for cervical cancer.

Lay Summary

We conducted a study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) from 2008 to 2012. We compared how often people attended different types of health care and costs of health care among adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls). The study included 1507 adults with ASD, 9042 with ADHD but not ASD, and 15,070 GP controls with no ASD or ADHD. Health care and cost data were obtained from KPNC databases for the year 2012. The study found that adults with ASD used more outpatient visits for primary care, mental health, and laboratory services than adults with ADHD. Gynecology visits and screening for cervical cancer were less common among women with ASD than among women with ADHD or GP. Health care costs for adults with ASD were higher than costs for adults with ADHD and costs for GP. In conclusion, adults with ASD had higher rates of use of most health care service areas than adults with ADHD or GP; however, women with ASD were less likely to have gynecology visits and have screening for cervical cancer.