Medicaid expenditures for children with autistic spectrum disorders: 1994 to 1999

A Scoping Review of the Intersectionality of Autism and Intellectual and Developmental Disability with Social Inequity on Diagnosis and Treatment of Youth

Objective: To describe how the intersectionality of race, ethnicity, and language with autism and intellectual and developmental disability (IDD) impacts mental health inequities in psychopharmacological management of youth. Method: This was a scoping review in which a series of searches were conducted in PubMed, Web of Science, Google Scholar, and manual review of the articles collected. Results: Although autism and/or IDD increases the risk for poor physical and mental health, social determinants of health such as race, ethnicity, and language account for approximately a third of poor outcomes. Minoritized children with autism/IDD experience significantly greater delays to diagnosis and misdiagnosis and are less likely to receive appropriate services. Access to psychological testing and psychosocial services is often limited by availability, skilled practitioners, a shortage of non-English-language providers or interpreters, and poor reimbursement. Conclusion: The intersectionality of autism and/or IDD with race, ethnicity, and language compounds the health inequities associated with either of these challenges independently.

The economic burden of autism spectrum disorder with and without intellectual disability in China: A nationwide cost-of-illness study

OBJECTIVE

The economic burden of autism spectrum disorder (ASD) on individuals, their families and society as a whole is poorly understood. Accurate figures are crucial for economic estimates and service planning.

METHODS

The total lifetime individual costs and annual societal costs of ASD in China were estimated with a prevalence-based, gross cost of illness approach and data from multiple sources. The direct medical costs in outpatient and inpatient settings from the electronic health records (EHRs) of hospitals, and direct nonmedical costs from a national survey were included. The indirect costs were from both the national survey and the estimation using human capital methods. Age-specific lifetime incremental societal costs were measured. Comorbidity-related and unrelated costs were analyzed separately.

RESULTS

The discounted lifetime cost for an individual with ASD in China was $2.65 million (at 2020 prices, $) for those without intellectual disability (ID) and $4.61 million (at 2020 prices, $) for those with ID. The total cost of ASD amounted to $41.8 billion in 2020. Productivity loss were major cost drivers for ASD individuals without ID. Direct nonmedical costs (rehabilitation or adult care costs etc.) were major drivers for ASD individuals with ID. In a lifetime course, the total annual costs for middle aged and elderly (>42 years) were highest, followed by transitional adults (18-29 years) and preschoolers, both for individuals with or without ID. The distribution of costs over the lifespan varied by the cost category.

CONCLUSIONS

ASD imposes a substantial economic burden on families and health care systems. Sectors and services coordination should be given policy considerations.

Direct and indirect costs for families of children with autism spectrum disorder in China

LAY ABSTRACT

This is the first comprehensive national study to explore the direct and indirect costs for families of children with autism spectrum disorder in China. The increasing prevalence of autism spectrum disorder highlights a growing need for resources to provide care for families of children with autism spectrum disorder. The medical and nonmedical costs and parents' productivity loss have caused a serious burden on their families. Our objective is to estimate the direct and indirect costs for the families of children with autism spectrum disorder in China. The target population was parents of children with autism spectrum disorder. We analyzed the costs using cross-sectional data from a Chinese national family survey with children aged 2-6 years (N = 3236) who were clinically diagnosed with autism spectrum disorder. Family data from 30 provinces in China were obtained. Cost items included direct medical costs, direct nonmedical costs, and indirect costs. In this study, we found that the largest part of family costs for autism spectrum disorder are nonmedical costs and productivity loss. Autism spectrum disorder has imposed a huge economic burden on parents having children with autism spectrum disorder in China, who need more support than the current health care system provides.

Link between the skin and autism spectrum disorder

Autism spectrum disorder (ASD) is a common neurological disorder. Although the etiologies of ASD have been widely speculated, evidence also supports the pathogenic role of cutaneous inflammation in autism. The prevalence of ASD is higher in individuals with inflammatory dermatoses than in those without inflammatory diseases. Anti-inflammation therapy alleviates symptoms of ASD. Recent studies suggest a link between epidermal dysfunction and ASD. In the murine model, mice with ASD display epidermal dysfunction, accompanied by increased expression levels of proinflammatory cytokines in both the skin and the brain. Children with ASD, which develops in their early lifetime, also exhibit altered epidermal function. Interestingly, improvement in epidermal function alleviates some symptoms of ASD. This line of evidence suggests a pathogenic role of cutaneous dysfunction in ASD. Either an improvement in epidermal function or effective treatment of inflammatory dermatoses can be an alternative approach to the management of ASD. We summarize here the current evidence of the association between the skin and ASD.

Health conditions and service use of autistic women and men: A retrospective population-based case-control study

LAY ABSTRACT

This study used administrative data from Ontario, Canada to compare the health conditions and service use of autistic women and men with adults with other developmental disabilities and with adults without developmental disabilities. Autistic women and men were more likely to have physical and mental health conditions compared to adults without developmental disabilities. Rates of health conditions were similar or lower among autistic adults compared to adults with other developmental disabilities, except more autistic adults had psychiatric conditions. Autistic women and men used higher rates of psychiatric services compared to all other groups. When comparing autistic women with same aged autistic men, sex differences were found for specific physical (Crohn's disease/colitis, rheumatoid arthritis) and psychiatric conditions (psychotic disorders, non-psychotic disorders), as well differences in service use (emergency department visits, hospitalizations, family doctor and neurologist visits). These results further highlight the high health needs and service use of autistic women and men, as well as adults with other developmental disabilities. It is critical for future research to focus on mental health support for autistic adults and to better understand how to tailor supports to best serve autistic women.

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.

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.

Medicaid Disruption Among Transition-Age Youth on the Autism Spectrum

Enrollment in Medicaid facilitates access to needed services among transition-age youth on the autism spectrum and youth with intellectual disability (ID). There are long-standing programs to ensure that individuals with ID remain enrolled as they age; similar programs for autistic youth are newer, not as widespread, and may not be as effective. We compared Medicaid disenrollment and re-enrollment between transition-age youth on the autism spectrum, youth with ID, and youth with both diagnoses using a national claims-based prospective cohort study from 2008 through 2012. Autistic youth were most likely to disenroll and least likely to re-enroll. Disenrollment peaked for all three groups at ages 19 and 21. Transition-age youth on the autism spectrum experience more disruptions in access to Medicaid-reimbursed services than youth with ID. More equitable Medicaid enrollment options for autistic individuals are needed to ensure their access to critical health care as they age.

Post-graduate Medical Training in Intellectual and Developmental Disabilities: a Systematic Review

OBJECTIVE

Despite the increasing number of people with autism-spectrum disorder (ASD), intellectual disabilities (ID), and developmental disabilities (DDs), individuals with these conditions continue to have high levels of unmet physical and mental health needs. Robust training of health professionals can help bridge this gap. A systematic review was conducted to describe the features and educational outcomes of existing postgraduate medical education curricula to inform the development of future training to address the growing unmet care needs of people with intellectual and developmental disabilities (IDD) such as ASD and ID.

METHODS

Four major databases were searched for peer-reviewed, English-language research focusing on post-graduate training in IDD education. Educational curricula and outcomes were summarized including Best Evidence in Medical Education (BEME) Quality of Evidence and Kirkpatrick training evaluation model.

RESULTS

Sixteen studies were identified with a majority published after 2000 (69%). Pediatric departments were involved in 69%, Psychiatry 19%, Medicine-Pediatrics 19%, and Family Medicine 6.3%. Analysis of Kirkpatrick outcomes showed 31% were level 1 (satisfaction or comfort); 38% level 2 (change in objective knowledge or skills); 13% level 3 (change in behavior); and none at level 4. BEME analysis showed 19% of studies were grade 1 (no clear conclusions), 31% grade 2 (ambiguous results), and half (50%) grade 3 (conclusions can probably be based on findings), with none scoring four or higher.

CONCLUSIONS

There is a paucity of objectively evaluated research in the area. Studies reviewed show clear promise for specialized, interdisciplinary, competency-based education which may be foundational for future curriculum development.

Biological Timing and Neurodevelopmental Disorders: A Role for Circadian Dysfunction in Autism Spectrum Disorders

Autism spectrum disorders (ASDs) are a spectrum of neurodevelopmental disorders characterized by impaired social interaction and communication, as well as stereotyped and repetitive behaviors. ASDs affect nearly 2% of the United States child population and the worldwide prevalence has dramatically increased in recent years. The etiology is not clear but ASD is thought to be caused by a combination of intrinsic and extrinsic factors. Circadian rhythms are the ∼24 h rhythms driven by the endogenous biological clock, and they are found in a variety of physiological processes. Growing evidence from basic and clinical studies suggest that the dysfunction of the circadian timing system may be associated with ASD and its pathogenesis. Here we review the findings that link circadian dysfunctions to ASD in both experimental and clinical studies. We first introduce the organization of the circadian system and ASD. Next, we review physiological indicators of circadian rhythms that are found disrupted in ASD individuals, including sleep-wake cycles, melatonin, cortisol, and serotonin. Finally, we review evidence in epidemiology, human genetics, and biochemistry that indicates underlying associations between circadian regulation and the pathogenesis of ASD. In conclusion, we propose that understanding the functional importance of the circadian clock in normal and aberrant neurodevelopmental processes may provide a novel perspective to tackle ASD, and clinical treatments for ASD individuals should comprise an integrative approach considering the dynamics of daily rhythms in physical, mental, and social processes.

Estimating Components and Costs of Standard Care for Children with Autism Spectrum Disorder in Europe from a Large International Sample

(1) Background: European guidelines provide recommendations for services and care for people with autism spectrum disorder (ASD), but not all interventions are generally available. Knowledge of service use and costs and wider societal costs in Europe is limited; (2) Method: Using an international sample, we analysed services and costs in 357 children (4-6.99 years) with ASD based on parent reports. Costs were transformed into EU-28 average using purchasing power parity; (3) Results: 122 children (34%) received specialist autism services; 149 (42%) received sensory/motor therapy; 205 (57%) received speech/language therapy; 35 (10%) received play therapy; 55 (15%) received behavioural interventions; 31 (9%) received social skills training; 47 (13%) participated in therapeutic recreational activities; and 59 (17%) received other services. The total number of hours for these services combined over two months was M = 34 (SD = 63; range: 0 -372). Estimated total costs of health-related services were M = 1210 EUR (SD = 2160 EUR); indirect societal costs were M = 1624 EUR (SD = 1317 EUR). Regression analyses suggested that costs rise with age and presence of intellectual disabilities, but not with severity of autism; (4) Conclusions: The high extent of community-based services indicates good accessibility but also considerable variation in the receipt of services. The costs of autism services are considerable. Further research is needed to investigate whether services received match individual needs.

The Safety and Effectiveness of High-Dose Propranolol as a Treatment for Challenging Behaviors in Individuals With Autism Spectrum Disorders

PURPOSE/BACKGROUND

Individuals with autism spectrum disorders present with social communication deficits and a rigid adherence to sameness. Along with these symptoms, many individuals also present with severe challenging behaviors that place themselves as well as their families and communities at risk for injury. For these individuals, new and effective treatments are acutely needed. Propranolol has been used worldwide for over 50 years. Its primary indication is for hypertension, but there is evidence that, at higher doses, propranolol inhibits rage and anger through its effects on the central nervous system. This effect has been demonstrated in a variety of neuropsychiatric disorders.

METHODS/PROCEDURES

Here, we present 46 retrospective analyses of clinical cases that were followed by a psychiatrist. Propranolol was prescribed as an add-on to the patients' existing medications. The doses ranged from 120 to 960 mg per day (mean = 462 mg).

FINDINGS/RESULTS

Thirty-nine (85%) of 46 patients were found to be much improved or very much improved on the physician-rated Clinical Global Impression Improvement scale. There were few side effects noted, with only 2 subjects unable to tolerate the propranolol.

IMPLICATIONS/CONCLUSIONS

It appears that high-dose propranolol can be given safely with minimal adverse cardiovascular problems, provided that close clinical monitoring is maintained. A more rigorous clinical trial is needed to elucidate and verify its clinical utility, clinical practice parameters, and the effects of propranolol as a monotherapy versus as an add-on to the patient's existing medication regimen.

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.

A Comparison of Health Care Expenditures for Medicaid-Insured Children with Autism Spectrum Disorder and Asthma in an Expanding Accountable Care Organization

As value-based care continues to expand, more children with autism spectrum disorder (ASD) will be treated by accountable care organizations (ACOs), provider organizations seeking to improve population health while reducing costs. To inform ACO strategies for children with ASD, this study compared health care expenditures of children insured by a Medicaid managed care organization, empaneled to a safety net ACO, with ASD, asthma, and neither diagnosis. Compared to other study groups, children with ASD were more costly, had lower rates of acute care, and had higher rates of "leaked" care provided by home- and community-based mental health agencies outside of the ACO. These findings highlight the need for unique value-based strategies for children with ASD in a public sector ACO.

Trends in Supplemental Security Income Payments to Adults With Autism

OBJECTIVE

This study used Social Security Administration program data to identify population-level trends in Supplemental Security Income (SSI) program participation and payments to adult recipients with autism spectrum disorder (ASD) relative to recipients with intellectual disability and other mental disorders.

METHODS

The authors examined SSI program data from 2005 to 2015. Variables included caseload size, number of new adult awardees per year, total annual SSI payments per disability group, and average annual SSI payment per recipient.

RESULTS

Adults with ASD represented a growing share of the total first-time SSI awards given to adults with mental disorders, with percentages increasing from 1.3% in 2005 to 5.0% in 2015. In 2015, 158,105 adults with ASD received SSI benefits, a 326.8% increase since 2005. Federal SSI payments to adults with ASD increased by 383.2% during the same period (totaling roughly $1.0 billion in 2015). The annual average payment for adults with ASD was $6,527.40 in 2015.

CONCLUSIONS

The purpose of the SSI program is to reduce the extent of poverty by providing monthly payments to eligible individuals with disabilities. The authors found that a large and growing number of adults with autism receive SSI benefits. This finding underscores the importance of future research related to the economic security of adults on the autism spectrum.

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.

Addressing Challenging Behavior During Hospitalizations for Children with Autism: A Pilot Applied Behavior Analysis Randomized Controlled Trial

This study evaluated the feasibility, acceptance, and potential clinical benefit of brief applied behavior analysis (ABA)-based interventions for children and adolescents with autism spectrum disorder (ASD) displaying challenging behaviors during hospitalizations. Participants included 36 children diagnosed with ASD, 6-17 years of age, who were medically or psychiatrically hospitalized. Children in the intervention group received a brief ABA intervention and were compared to children in the evaluation and monitoring-only group. Families and staff recommended the intervention, children receiving the intervention demonstrated significantly more improvement in unblinded ratings of clinical severity, data from physicians indicated a positive effect of the intervention on levels of staffing and restraints and attending medical providers universally reported satisfaction and benefit of the intervention. Improvements in challenging behaviors were not significantly different as reported by parents, and the length of hospitalization did not differ between the groups. Ultimately, the outcomes of this pilot study suggest incorporating specialized ABA-based assessment and intervention during hospitalization may be feasible and well accepted by clinicians and families. However, future research must address potent methodological challenges related to capturing meaningful data during hospitalizations in order to answer questions of ultimate pragmatic, clinical, and system-level benefits. Trial Registration ClinicalTrials.gov Identifier NCT02339935, Registered 16 January 2015, First participant consented 23 February 2015. Autism Res 2020, 13: 1072-1078. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Inpatient hospitalizations for children with autism spectrum disorder (ASD) and severe behavior are common, challenging, and costly in terms of human experience. This study evaluated the benefit of brief applied behavior analysis-based interventions to children and adolescents with ASD displaying challenging behaviors during hospitalizations. Families and staff evaluating the procedures noted perceived potential benefits of the intervention, but this initial pilot study did not document changes in hospitalization length or blinded rating of improvement.

Screening Tools for Autism Spectrum Disorder in Primary Care: A Systematic Evidence Review

CONTEXT

Recommendations conflict regarding universal application of formal screening instruments in primary care (PC) and PC-like settings for autism spectrum disorder (ASD).

OBJECTIVES

We systematically reviewed evidence for universal screening of children for ASD in PC.

DATA SOURCES

We searched Medline, PsychInfo, Educational Resources Informational Clearinghouse, and Cumulative Index of Nursing and Allied Health Literature.

STUDY SELECTION

We included studies in which researchers report psychometric properties of screening tools in unselected populations across PC and PC-like settings.

DATA EXTRACTION

At least 2 authors reviewed each study, extracted data, checked accuracy, and assigned quality ratings using predefined criteria.

RESULTS

We found evidence for moderate to high positive predictive values for ASD screening tools to identify children aged 16 to 40 months and 1 study for ≥48 months in PC and PC-like settings. Limited evidence evaluating sensitivity, specificity, and negative predictive value of instruments was available. No studies directly evaluated the impact of screening on treatment or harm.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and a constrained search.

CONCLUSIONS

ASD screening tools can be used to accurately identify percentages of unselected populations of young children for ASD in PC and PC-like settings. The scope of challenges associated with establishing direct linkage suggests that clinical and policy groups will likely continue to guide screening practices. ASD is a common neurodevelopmental disorder associated with significant life span costs.^1,2 Growing evidence supports functional gains and improved outcomes for young children receiving intensive intervention, so early identification on a population level is a pressing public health challenge.^3,4.

The Economic Costs of Autism Spectrum Disorder: A Literature Review

Autism is associated with a range of costs. This paper reviews the literature on estimating the economic costs of autism spectrum disorder (ASD). More or less 50 papers covering multiple countries (US, UK, Australia, Canada, Sweden, the Netherlands, etc.) were analysed. Six types of costs are discussed in depth: (i) medical and healthcare service costs, (ii) therapeutic costs, (iii) (special) education costs, (iv) costs of production loss for adults with ASD, (v) costs of informal care and lost productivity for family/caregivers, and (vi) costs of accommodation, respite care, and out-of-pocket expenses. A general finding is that individuals with ASD and families with children with ASD have higher costs. Education costs appear to be a major cost component for parents with children with ASD.

Case Identification and Characterization of Autistic Young Adults in 2010 Medicare Fee-for-Service Claims

Background

Medicare is a public insurer for whom many autistic adults are eligible in the United States, but little is known about autistic beneficiaries who are covered. A challenge in using claim data is identification of autism spectrum disorder (ASD) cases to ensure accurate characterization. Some work suggests that relying on one claim could identify probable ASD, although other works indicate that two claims are necessary for case identification. The purpose of the current study was to describe the sample of Medicare young adult beneficiaries, and determine whether using a 1+ versus 2+ claim case identification resulted in similar interpretation of sample demographic characteristics and primary care utilization patterns in Medicare professional service claims.

Methods

We used Medicare Limited Data Sets (2008-2010) claims. After ASD case identification using ICD-9-CM (299.xx), 527 unique beneficiaries in the last claim year of 2010 professional service file were identified as having at least one claim of ASD. Of these, 69% (n = 364) had two or more claims. Proportions and zero-inflated negative binomial regression were used to examine differences in demographic characteristics and primary care utilization and costs for the 1+ and 2+ samples.

Results

Medicare claims contain a sample of autistic adults with expected demographics identified in historic prevalence cohorts. No differences in age, gender, race/ethnicity, Hispanic status, or dual-eligibility months or Adjusted Clinical Groups (ACG)^® concurrent risk scores were identified between the 1+ and 2+ samples. No difference was found in the overall estimation of primary care use or costs between the 1+ and 2+ samples based on Zellner's seemingly unrelated regression methods.

Conclusions

This study is the first to describe a national sample of Medicare-insured autistic adults. We found that using a 1+ case identification results in a sample that is demographically similar to a 2+ claim sample, and produces similar estimates of utilization as a 2+ claim sample.

In-hospital mortality among adults with autism spectrum disorder in the United States: A retrospective analysis of US hospital discharge data

A retrospective data analysis using 2004-2014 Healthcare Cost and Utilization Project Nationwide Inpatient Sample was conducted to examine in-hospital mortality among adults with autism spectrum disorders in the United States compared to individuals in the general population. We modeled logistic regressions to compare inpatient hospital mortality between adults with autism spectrum disorders (n = 34,237) and age-matched and sex-matched controls (n = 102,711) in a 1:3 ratio. Adults with autism spectrum disorders had higher odds for inpatient hospital mortality than controls (odds ratio = 1.44, 95% confidence interval: 1.29-1.61, p < 0.001). This risk remained high even after adjustment for age, sex, race/ethnicity, income, number of comorbidities, epilepsy and psychiatric comorbidities, hospital bed size, hospital region, and hospitalization year (odds ratio = 1.51, 95% confidence interval: 1.33-1.72, p < 0.001). Adults with autism spectrum disorders who experienced in-hospital mortality had a higher risk for having 10 out of 27 observed Elixhauser-based medical comorbidities at the time of death, including psychoses, other neurological disorders, diabetes, hypothyroidism, rheumatoid arthritis collagen vascular disease, obesity, weight loss, fluid and electrolyte disorders, deficiency anemias, and paralysis. The results from the interaction of sex and autism spectrum disorders status suggest that women with autism spectrum disorders have almost two times higher odds for in-hospital mortality (odds ratio = 1.95, p < 0.001) than men with autism spectrum disorders. The results from the stratified analysis also showed that women with autism spectrum disorders had 3.17 times higher odds (95% confidence interval: 2.50-4.01, p < 0.001) of in-hospital mortality compared to women from the non-autism spectrum disorders matched control group; this difference persisted even after adjusting for socioeconomic, clinical, and hospital characteristics (odds ratio = 2.75, 95% confidence interval: 2.09-3.64, p < 0.001). Our findings underscore the need for more research to develop better strategies for healthcare and service delivery to people with autism spectrum disorders.

Utilization and medical costs of outpatient rehabilitation among children with autism spectrum conditions in Taiwan

Background

We examined the utilization of rehabilitation resources among children with autism spectrum condition (ASC), a neurodevelopmental condition, in Taiwan.

Methods

We derived from the National Health Insurance Research Database of Taiwan data pertaining to 3- to 12-year-old children for the period 2008–2010. Based on diagnoses executed in accordance with the International Classification of Diseases, Ninth Revision, Clinical Modification, we classified these data into the ASC and non-ASC groups and analyzed them through multiple linear regression model, negative binomial model, independent sample t testing, and χ² testing.

Results

Compared with the non-ASC group, the ASC group exhibited higher utilization of rehabilitation resources. Because hospitals are constrained by overall expenditure limits, expenditure on rehabilitation resources has plateaued, preventing any increase in the utilization of rehabilitation resources. In our ASC group, preschool-aged children significantly outnumbered (p < 0.001) school-aged children. When stratified by the hospital level, district hospitals reported the highest utilization (p < 0.001). When stratified by region, the highest utilization was in Taipei, whereas the lowest was in the East region (p < 0.001). The total annual cost, average frequency of visits, utilization of rehabilitation resources, and average cost were all affected by such elements as patient demographics, hospital type and location (p < 0.001).

Conclusions

For improving treatment outcomes among children with ASC and decreasing treatment expenditure, policies that promote the timely ASC detection and treatment should be implemented.

Focus on the Social Aspect of Autism

Autism spectrum disorder (ASD) describes a set of neurodevelopmental disorders. Despite extensive ASD research lasting more than 60 years, its causes are still unknown. Without indicating the etiology, its development cannot be stopped. Over the years, both the definition and diagnostic criteria have developed. The number of ASD incidence is rising. The economical aspect should also be highlighted. This disorder presents particular challenges to affected children, their parents and physicians. The research of ASD, physician activities, policy making and raising the level of awareness must be coordinated. Special attention should be paid to the problem among adults with ASD.

Autism spectrum disorder, politics, and the generosity of insurance mandates in the United States

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians–with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America.

Leadership profiles associated with the implementation of behavioral health evidence-based practices for autism spectrum disorder in schools

Implementation of evidence-based practice (EBP) for autism spectrum disorder (ASD) in the education system is a public health priority. Leadership is a critical driver of EBP implementation but little is known about the types of leadership behaviors exhibited by school leaders and how this influences the context of EBP implementation, particularly for students with ASD. The objectives of this study were to determine (1) the leadership profiles of principals involved in EBP implementation for students with ASD and (2) how these leadership profiles related to school characteristics and implementation climate. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework was used to guide the design and analysis of this study. Participants (n = 296) included principals, teachers, and classroom support staff. They provided demographic information and completed the Multifactor Leadership Questionnaire and Implementation Climate Scale. Using latent profile analysis, a three-pattern solution was identified: Disengaged (6% of sample), Undifferentiated (23% of sample), and Optimal (71% of sample). Principals in schools with higher proportions of students with an individualized education program were more likely to be classified as Undifferentiated than Optimal. The Optimal group was associated with more positive implementation climate than the Undifferentiated or Disengaged groups. Findings suggest that leadership behaviors rated by principals and their staff involved in implementation of common autism EBPs can be meaningfully clustered into three discernible profiles that are shaped by organizational context and linked to strategic implementation climate. Our study findings have implications for leadership training and service delivery in schools by underscoring the critical nature of school leadership during implementation of EBPs for children with autism and the interplay between specific leadership behaviors and strategic implementation climate.

Individual and organizational factors that affect implementation of evidence-based practices for children with autism in public schools: a cross-sectional observational study

BACKGROUND

Children with autism receive most of their intervention services in public schools, but implementation of evidence-based practices (EBPs) for autism varies. Studies suggest that individual (attitudes) and organizational characteristics (implementation leadership and climate) may influence providers' use of EBPs, but research is relatively limited in this area. This study examined individual and organizational factors associated with implementation of three EBPs-discrete trial training, pivotal response training, and visual schedules-for children with autism in special education classrooms in public elementary schools.

METHODS

Participants included 67 autism support teachers and 85 other classroom staff from 52 public elementary schools in the northeastern United States. Participants reported their attitudes toward EBPs (e.g., intuitive appeal, willingness if required, openness, and divergence), implementation leadership and climate of their school, and the frequency with which they deliver each of three EBPs. Linear regression was used to estimate the association of attitudes about EBPs with organizational characteristics and intensity of EBP use. Demographic covariates with a bivariate association with EBP use significant at p < .20 were entered into the adjusted models.

RESULTS

There were significant findings for only one EBP, discrete trial training. Teachers who reported higher perceived divergence (perceived difference of usual practice with academically developed or research-based practices) between EBPs and current practices used less discrete trial training (f2 = .18), and teachers who reported higher appeal (willingness to adopt EBPs given their intuitive appeal) of EBPs used more discrete trial training (f2 = .22). No organizational factors were significantly associated with implementation with any of the three EBPs.

CONCLUSIONS

Attitudes toward EBPs may affect teachers' decisions to use EBPs; however, implementation leadership and climate did not predict EBP use. Future implementation efforts ought to consider the type of EBP and its fit within the context in terms of the EBP's similarities to and differences from existing practices and programs in the setting. Implementation strategies that target individual attitudes about EBPs may be warranted in public schools.

Predictors of Inpatient Psychiatric Hospitalization for Children and Adolescents with Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is associated with significant healthcare expenditures and a greater utilization of psychiatric health services. High utilization may not be evenly distributed across individuals with ASD. The objective of this study was to identify individual and family characteristics that increase the risk of psychiatric hospitalization. Naturalistic study of two age- and gender-matched ASD cohorts, inpatients enrolled in the Autism Inpatient Collection (AIC) and outpatients enrolled in the Rhode Island Consortium of Autism Research and Treatment (RI-CART), revealed a number of factors associated with hospitalization. Multiple logistic regression analyses revealed that adaptive functioning, ASD symptom severity, primary caregiver's marital status, the presence of mood disorders, and the presence of sleep problems independently increased the risk of psychiatric hospitalization.

Dental utilization and expenditures by children and adolescents with autism spectrum disorders: A population-based cohort study

Objectives:

It is understood that children and adolescents with autism spectrum disorders (ASDs) have difficulty in receiving dental treatment. This study explores the differences in dental utilization and expenditure between two groups: children and adolescents with and without ASD. Different conditions that affect these results will be examined, including area of residence, category of treatment, and preferences concerning type of dental institution in Taiwan.

Materials and Methods:

The health service research database of the National Health Research Institutes, which features population-based, randomly selected samples collected from 2001 to 2010, was utilized in this study. In particular, we recruited samples from 2005 in accordance with the codes of the International Classification of Diseases, 9^th revision, Clinical Modification from 299.0 to 299.9. The population-based cohort study measured mean expenditures and mean numbers of medical visits with regard to different dental institution classifications, areas of residence, and categories of dental treatment for children (under 18 years old) with and without ASD.

Results:

The mean number of annual visits was 6.58 and 5.70 for children and adolescents with and without ASD, respectively, with mean annual visit expenditures of NT$2401.20 and NT$1817.99, respectively. A higher percentage of children (91.32%) and adolescents (72.66%) with ASD had experienced dental treatment than those without ASD. Children (93.23%) and adolescents (90.83%) without ASD visited dental clinics more often than those with ASD. The percentage of dental visits to academic medical centers in Eastern Taiwan was significantly lower for the ASD group than visits to other types of dental institutions. The use of restorative treatment was significantly higher among all samples, with periodontology having the lowest percentage.

Conclusions:

Children and adolescents with ASD had greater dental utilization, expenditures, and preferences for high-level dental institutions. The discrepancies in dental utilization indicate differences in the distribution of medical resources in different dental institution levels and residence areas in Taiwan.

ECHO Autism

Children with autism spectrum disorder (ASD) have complex medical problems, yet they are at high risk for unmet health care needs. Primary care providers are perfectly positioned to meet these needs; however, they often lack training in ASD. This pilot project developed and tested a new model for training primary care providers in best-practice care for ASD using the Extension for Community Healthcare Outcomes (ECHO) framework. The 6-month ECHO Autism pilot project consisted of 12 biweekly clinics focused on screening and identification of ASD symptoms and management of medical and psychiatric comorbidities. Participants completed measures of practice behavior and self-efficacy in screening and management of children with ASD at baseline (pretest) and after 6 months of ECHO Autism (posttest). Statistically significant improvements were observed in self-efficacy, in adherence to ASD screening guidelines, and in use of ASD-specific resources. Participants also reported high satisfaction with the program.

Increased Service Use Among Children With Autism Spectrum Disorder Associated With Mental Health Parity Law

Health care services for children with autism spectrum disorder are often expensive and frequently not covered under private health insurance. The 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was viewed as a possible means of improving access by eliminating differences between behavioral health and medical/surgical benefits. We examined whether the legislation was associated with increased use of and spending on mental health care and functional services for children with autism spectrum disorder compared to the period prior to implementation of the law. We used nationwide health insurance commercial group claims data to examine trends in service use and spending among children with autism spectrum disorder before and after implementation of the law. For such children, implementation was associated with increased use of both mental health and non-mental health services. These increases in use were not associated with higher out-of-pocket spending, which suggests that the law improved financial protection for families.

Comorbidity prevalence, healthcare utilization, and expenditures of Medicaid enrolled adults with autism spectrum disorders

A retrospective data analysis using 2000-2008 three state Medicaid Analytic eXtract was conducted to examine the prevalence and association of comorbidities (psychiatric and non-psychiatric) with healthcare utilization and expenditures of fee-for-service enrolled adults (22-64 years) with and without autism spectrum disorders (International Classification of Diseases, Ninth Revision-clinical modification code: 299.xx). Autism spectrum disorder cases were 1:3 matched to no autism spectrum disorder controls by age, gender, and race using propensity scores. Study outcomes were all-cause healthcare utilization (outpatient office visits, inpatient hospitalizations, emergency room, and prescription drug use) and associated healthcare expenditures. Bivariate analyses (chi-square tests and t-tests), multinomial logistic regressions (healthcare utilization), and generalized linear models with gamma distribution (expenditures) were used. Adults with autism spectrum disorders (n = 1772) had significantly higher rates of psychiatric comorbidity (81%), epilepsy (22%), infections (22%), skin disorders (21%), and hearing impairments (18%). Adults with autism spectrum disorders had higher mean annual outpatient office visits (32_ASD vs 8_noASD) and prescription drug use claims (51_ASD vs 24_noASD) as well as higher mean annual outpatient office visits (US$4375_ASD vs US$824_noASD), emergency room (US$15,929_ASD vs US$2598_noASD), prescription drug use (US$6067_ASD vs US$3144_noASD), and total expenditures (US$13,700_ASD vs US$8560_noASD). The presence of a psychiatric and a non-psychiatric comorbidity among adults with autism spectrum disorders increased the annual total expenditures by US$4952 and US$5084, respectively.

Psychiatric comorbidity in autism spectrum disorder: Correspondence between mental health clinician report and structured parent interview

Publicly funded mental health services are critical in caring for children with autism spectrum disorder. Accurate identification of psychiatric comorbidity is necessary for effective mental health treatment. Little is known about psychiatric diagnosis for this population in routine mental health care. This study (1) examined correspondence between psychiatric diagnoses reported by mental health clinicians and those derived from a structured diagnostic interview and (2) identified predictors of agreement between clinician-reported and diagnostic interview-derived diagnoses in a sample of 197 children aged 4-14 years with autism spectrum disorder receiving mental health services. Data were drawn from a randomized effectiveness trial conducted in publicly funded mental health services. Non-autism spectrum disorder diagnoses were assessed using an adapted version of the Mini-International Neuropsychiatric Interview, parent version. Cohen's kappa was calculated to examine agreement between Mini-International Neuropsychiatric Interview, parent version and clinician-reported diagnoses of comorbid conditions. Children met criteria for an average of 2.83 (standard deviation = 1.92) Mini-International Neuropsychiatric Interview, parent version diagnoses. Agreement was poor across all diagnostic categories (κ values: 0.06-0.18). Logistic regression identified child gender and clinical characteristics as significant predictors of agreement for specific diagnoses. Results underscore the need for training mental health clinicians in targeted assessment of specific psychiatric disorders and prioritizing treatment development and testing for specific diagnoses to improve care for children with autism spectrum disorder served in publicly funded mental health settings.

Challenges in the diagnosis and treatment of depression in autism spectrum disorders across the lifespan

Diagnosis and treatment of comorbid neuropsychiatric illness is often a secondary focus of treatment in individuals with autism spectrum disorder (ASD), given that substantial impairment may be caused by core symptoms of ASD itself. However, psychiatric comorbidities, including depressive disorders, are common and frequently result in additional functional impairment, treatment costs, and burden on caregivers. Clinicians may struggle to appropriately diagnose depression in ASD due to communication deficits, atypical presentation of depression in ASD, and lack of standardized diagnostic tools. Specific risk and resilience factors for depression in ASD across the lifespan, including level of functioning, age, family history, and coping style, have been suggested, but require further study. Treatment with medications or psychotherapy may be beneficial, though more research is required to establish guidelines for management of symptoms. This review will describe typical presentations of depression in individuals with ASD, review current information on the prevalence, assessment, and treatment of comorbid depression in individuals with ASD, and identify important research gaps.

Translating Research to Practice for Children With Autism Spectrum Disorder: Part 2: Behavior Management in Home and Health Care Settings

INTRODUCTION

Managing home and health care for children with autism spectrum disorder can be challenging because of the range of symptoms and behaviors exhibited.

METHOD

This article presents an overview of the emerging science related to the methods to foster family self-management of common concerns regarding activities of daily living and behaviors, as well as for the health care provider in primary and acute health care settings.

RESULTS

Recommendations are provided to enhance the overall delivery of services, including understanding and managing a child's challenging behaviors, and supporting family management of common activities of daily living and behaviors.

DISCUSSION

Health care providers' knowledge of evidence-based recommendations for providing care, supporting family self-management of common concerns, and referral heighten the likelihood of better outcomes for children with autism spectrum disorder.

School-Based Behavioral Health Service Use and Expenditures for Children With Autism and Children With Other Disorders

OBJECTIVE

This study compared use of and associated expenditures for Medicaid-reimbursed school-based and out-of-school services for children with autism spectrum disorder (ASD) and those with other psychiatric disorders.

METHODS

Philadelphia County Medicaid claims were used to identify children ages five to 17 who received behavioral health services through Medicaid any time between October 2008 and September 2009 (N=24,271). Children were categorized into four diagnostic groups: autism spectrum disorder (ASD), conduct disorder or oppositional defiant disorder (conduct-ODD), attention-deficit hyperactivity disorder (ADHD), and other psychiatric disorders. Logistic regression analysis compared use of in-school and out-of-school behavioral health services between children with ASD and children with other psychiatric disorders. Generalized linear models with gamma distribution were used to estimate differences in Medicaid expenditures for in-school and out-of-school services and total Medicaid expenditures for both service types by disorder, with adjustments for age, sex, and race-ethnicity.

RESULTS

The most common diagnosis was ADHD (40%); 35% had other psychiatric disorders, 21% had conduct-ODD, and 4% had ASD. A significantly greater proportion of children with ASD (52%) received in-school behavioral health services (conduct-ODD, 5%; ADHD, 8%; and other psychiatric disorders, 1.7%) Per-child expenditures for both school-based and out-of-school behavioral health services were significantly higher for children with ASD than for children in the other groups.

CONCLUSIONS

Medicaid represents an important source of in-school and out-of-school care for children with ASD and their families. States that expand Medicaid under the Affordable Care Act should give careful consideration to covering school-based mental health services for children with ASD.

Increasing Autism Awareness in Inner-City Churches: A Brief Report

Autism diagnosis rates trail significantly in the African American community. This pre-test post-test pilot study evaluated an African American inner-city church health ambassadors (HAs) autism spectrum disorder (ASD) awareness training session. The participants included 12 HAs who attended the 1 hour training session organized by the National Baptist Convention, USA, Inc. Results of surveys showed higher mean scores post training for (1) HA attitudes about the potential for children to improve with applied behavior analysis therapy; (2) HA self-efficacy for having information about ASD screening materials; (3) strategies HAs could use to help parents/caregivers of children with developmental delays and challenging behaviors; (4) HA confidence in referrals for children with signs of ASD; (5) HA knowledge of measures to take to maximize a child's chance of receiving an ASD evaluation; and (6) HA comfort for talking to parents about children with challenging behaviors. Several of these effects were maintained 3 months later. Findings underscore the usefulness of the intervention for increasing the dissemination of knowledge about ASD and the opportunity to positively affect ASD screening, early intervention, and policy standards applicable to this vulnerable population.

Frequency and correlates of service access among youth with autism transitioning to adulthood

This study examined service receipt and unmet service needs among youth with autism spectrum disorders (ASD) in their last year of high school, as well as the youth (intellectual disability, race/ethnicity, autism severity, comorbid psychiatric diagnoses, behavior problems, adaptive behavior) and family (income, parental health, parental depressive symptoms, parental anxiety) correlates of service access. Thirty-nine families of youth with ASD participated. Data were collected via parental interview/questionnaire and youth psychological evaluation. Results suggested that this sample was underserved relative to a nationally-representative cohort. Those with a comorbid psychiatric diagnosis and lower levels of adaptive behavior received more services. Greater unmet needs were reported for youth who were racial/ethnic minorities, who had more behavior problems, and whose parents had greater anxiety.

Factors associated with parental ratings of condition severity for children with autism spectrum disorder

BACKGROUND

There is currently little consensus on how the severity of a child's autism spectrum disorder (ASD) should be measured, and yet despite the lack of a standardized definition, parents were readily able to answer a question asking them to describe the severity of his/her child's ASD in a national survey.

OBJECTIVE

The current study examined factors associated with a parent's judgment of ASD severity, by identifying child and household characteristics that were associated with a parent's severity rating of his/her child's ASD, including child ASD symptomatology, child impact, and family impact.

METHODS

Data came from the 2011 Survey of Pathways to Diagnosis and Services ("Pathways"). A total of 967 parents in households with a child diagnosed with ASD between the ages of 6-17 were eligible for the current study. A measurement model was used to create latent factors of child symptoms, child impact, and family impact; multivariate logistic regression models examined the relationship between these latent factors and the parent's severity rating of their child's ASD.

RESULTS

Children with higher family impact factor scores were more likely to have parents who rated their child's ASD as the most severe. Surprisingly, symptomatology and impact on the child were less predictive of severe ratings.

CONCLUSIONS

A parent's conceptualization of their child's ASD severity may vary more as a function of the impact of the child's condition on the family and less as a function of the symptoms exhibited by the child or the impact directly felt by the child.

Autism and families' financial burden: the association with health insurance coverage

We examined the relationship between family financial burden and children's health insurance coverage in families (n  =  316) raising children with autism spectrum disorders (ASD), using pooled 2000-2009 Medical Expenditure Panel Survey data. Measures of family financial burden included any out-of-pocket spending in the previous year, and spending as a percentage of families' income. Families spent an average of $9.70 per $1,000 of income on their child's health care costs. Families raising children with private insurance were more than 5 times as likely to have any out-of-pocket spending compared to publicly insured children. The most common out-of-pocket expenditure types were medications, outpatient services, and dental care. This study provides evidence of the relative inadequacy of private insurance in meeting the needs of children with ASD.

Autism spectrum disorder and particulate matter air pollution before, during, and after pregnancy: a nested case-control analysis within the Nurses' Health Study II Cohort

BACKGROUND

Autism spectrum disorder (ASD) is a developmental disorder with increasing prevalence worldwide, yet has unclear etiology.

OBJECTIVE

We explored the association between maternal exposure to particulate matter (PM) air pollution and odds of ASD in her child.

METHODS

We conducted a nested case-control study of participants in the Nurses' Health Study II (NHS II), a prospective cohort of 116,430 U.S. female nurses recruited in 1989, followed by biennial mailed questionnaires. Subjects were NHS II participants' children born 1990-2002 with ASD (n = 245), and children without ASD (n = 1,522) randomly selected using frequency matching for birth years. Diagnosis of ASD was based on maternal report, which was validated against the Autism Diagnostic Interview-Revised in a subset. Monthly averages of PM with diameters ≤ 2.5 μm (PM2.5) and 2.5-10 μm (PM10-2.5) were predicted from a spatiotemporal model for the continental United States and linked to residential addresses.

RESULTS

PM2.5 exposure during pregnancy was associated with increased odds of ASD, with an adjusted odds ratio (OR) for ASD per interquartile range (IQR) higher PM2.5 (4.42 μg/m3) of 1.57 (95% CI: 1.22, 2.03) among women with the same address before and after pregnancy (160 cases, 986 controls). Associations with PM2.5 exposure 9 months before or after the pregnancy were weaker in independent models and null when all three time periods were included, whereas the association with the 9 months of pregnancy remained (OR = 1.63; 95% CI: 1.08, 2.47). The association between ASD and PM2.5 was stronger for exposure during the third trimester (OR = 1.42 per IQR increase in PM2.5; 95% CI: 1.09, 1.86) than during the first two trimesters (ORs = 1.06 and 1.00) when mutually adjusted. There was little association between PM10-2.5 and ASD.

CONCLUSIONS

Higher maternal exposure to PM2.5 during pregnancy, particularly the third trimester, was associated with greater odds of a child having ASD.

The difference in medical utilization and associated factors between children and adolescents with and without autism spectrum disorders

This study determined differences in health care utilization and health care expenditures between children with and without autism spectrum disorder (ASD) and examined possible reasons for these differences. A retrospective longitudinal study of children aged younger than 18 years both with and without ASD was conducted using the 2008 database of the Ministry of the Interior registry of the disabled persons in tandem with the National Health Insurance Research Database. Propensity score matching for the covariates of age, sex, and parental monthly salary was used to match children at a ratio of 1:3 for observing health care utilization among children with and without ASD from 2008 to 2011. Generalized estimating equation analysis was performed to determine factors that affect health care utilization, such as physician visits, emergency room (ER) visits, hospitalizations, and health care expenditures. After matching was completed, the sample size comprised 3280 children with ASD and 9840 children without ASD. Among the children in the sample, most were boys (86.68%) between the ages of 6-11 years, and the average age of both samples was 9.8 years. After relevant factors were controlled for, the children with ASD yielded an average of 14.2 more annual physician visits and were more likely to visit the ER (OR=1.12, P<.05) or be hospitalized (OR=1.48; P<.05) compared with the children without ASD. Compared with the children without ASD, the children with ASD exhibited higher annual physician visit expenditures (NT$26,580 more), higher ER visit expenditures (NT$50 more), higher hospitalization expenditures (NT$5830 more), and NT$32,460 more total health care expenditures (all P<.05). Significant predictors of health care expenditures among the children with ASD were age, parental monthly salary, and severity of comorbidity. The most common reasons for physician visits or hospitalizations among the children with ASD were psychiatric illnesses, respiratory illnesses, and digestive illnesses. The children without ASD most commonly experienced respiratory, digestive, and nervous system or sense organ illnesses. Health care utilization among children with ASD is higher than that among children without ASD. The results of this study can serve as a reference for governmental agencies enacting relevant health care policies.

The effects of mandated health insurance benefits for autism on out-of-pocket costs and access to treatment

As of 2014, 37 states have passed mandates requiring many private health insurance policies to cover diagnostic and treatment services for autism spectrum disorders (ASDs). We explore whether ASD mandates are associated with out-of-pocket costs, financial burden, and cost or insurance-related problems with access to treatment among privately insured children with special health care needs (CSHCNs). We use difference-in-difference and difference-in-difference-in-difference approaches, comparing pre--post mandate changes in outcomes among CSHCN who have ASD versus CSHCN other than ASD. Data come from the 2005 to 2006 and the 2009 to 2010 waves of the National Survey of CSHCN. Based on the model used, our findings show no statistically significant association between state ASD mandates and caregivers' reports about financial burden, access to care, and unmet need for services. However, we do find some evidence that ASD mandates may have beneficial effects in states in which greater percentages of privately insured individuals are subject to the mandates. We caution that we do not study the characteristics of ASD mandates in detail, and most ASD mandates have gone into effect very recently during our study period.

A cost of illness study of children with high-functioning autism spectrum disorders and comorbid anxiety disorders as compared to clinically anxious and typically developing children

The study's aim was to estimate the societal costs of children with high-functioning ASD and comorbid anxiety disorder(s) (ASD + AD-group; n = 73), and to compare these costs to children with anxiety disorders (AD-group; n = 34), and typically developing children (controls; n = 87). Mean total costs for the ASD + AD-group amounted <euro>17,380 per year. Societal costs were estimated at almost 142 million euro per year. Costs in the ASD + AD-group were four times higher compared to the AD-group, and 27 times higher compared to controls. ASD-related costs were higher in the ASD + AD-group; anxiety-related costs did not differ between the ASD + AD- and AD-group; costs due to physical or other reasons did not differ across groups. The findings suggest that costs can be decreased if effective treatment options for treating anxiety in ASD are established, however, the remaining costs associated with ASD would still be large. A limitation of the study is that a group of children with ASD without anxiety disorders is lacking.

Comparing service use and costs among adolescents with autism spectrum disorders, special needs and typical development

Autism spectrum disorder is a complex condition that requires specialised care. Knowledge of the costs of autism spectrum disorder, especially in comparison with other conditions, may be useful to galvanise policymakers and leverage investment in education and intervention to mitigate aspects of autism spectrum disorder that negatively impact individuals with the disorder and their families. This article describes the services and associated costs for four groups of individuals: adolescents with autistic disorder, adolescents with other autism spectrum disorders, adolescents with other special educational needs and typically developing adolescents using data from a large, well-characterised cohort assessed as part of the UK Special Needs and Autism Project at the age of 12 years. Average total costs per participant over 6 months were highest in the autistic disorder group (£11,029), followed by the special educational needs group (£9268), the broader autism spectrum disorder group (£8968) and the typically developing group (£2954). Specialised day or residential schooling accounted for the vast majority of costs. In regression analysis, lower age and lower adaptive functioning were associated with higher costs in the groups with an autism spectrum disorder. Sex, ethnicity, number of International Classification of Diseases (10th revision) symptoms, autism spectrum disorder symptom scores and levels of mental health difficulties were not associated with cost.

Annual research review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders

BACKGROUND

Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses.

SCOPE AND METHODS

The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012.

FINDINGS

Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8).

CONCLUSION

Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.

Economic burden of childhood autism spectrum disorders

OBJECTIVE

To estimate the associations between autism spectrum disorder (ASD) diagnoses and service use, caregiver time, and cost outcomes.

METHODS

We used national data from the Medical Expenditure Panel Survey linked to the National Health Interview Survey and a study-specific survey to estimate the annual utilization and costs for health care, school, ASD-related therapy, family-coordinated services, as well as caregiver time in children aged 3 to 17 years, with and without parent-reported ASD. Regression analyses estimated the association between ASD diagnosis and cost, controlling for child gender, age, race/ethnicity, insurance status, household income, country region and urban/rural classification, and non-ASD-related illnesses.

RESULTS

Children with parent-reported ASD had higher levels of health care office visits and prescription drug use compared with children without ASD (P < .05). A greater proportion of children in the ASD group used special educational services (76% vs. 7% in the control group, P < .05). After adjusting for child demographic characteristics and non-ASD-associated illnesses, ASD was associated with $3020 (95% confidence interval [CI]: $1017-$4259) higher health care costs and $14,061 (95% CI: $4390-$24,302) higher aggregate non-health care costs, including $8610 (95% CI: $6595-$10,421) higher school costs. In adjusted analyses, parents who reported that their child had ASD did not have significantly higher out-of-pocket costs or spend more time on caregiving activities compared with control parents.

CONCLUSIONS

The economic burden associated with ASD is substantial and can be measured across multiple sectors of our society. Previous analyses that focused on health care underestimated this economic burden, particularly for school systems.

Healthcare service use and costs for autism spectrum disorder: a comparison between medicaid and private insurance

Healthcare costs and service use for autism spectrum disorder (ASD) were compared between Medicaid and private insurance, using 2003 insurance claims data in 24 states. In terms of costs and service use per child with ASD, Medicaid had higher total healthcare costs ($22,653 vs. $5,254), higher ASD-specific costs ($7,438 vs. $928), higher psychotropic medication costs($1,468 vs. $875), more speech therapy visits (13.0 vs. 3.6 visits), more occupational/physical therapy visits (6.4 vs. 0.9 visits), and more behavior modification/social skills visits (3.8 vs. 1.1 visits) than private insurance (all p < 0.0001). In multivariate analysis, being enrolled in Medicaid had the largest effect on costs, after controlling for other variables. The findings emphasize the need for continued efforts to improve private insurance coverage of autism.