Age at diagnosis of autism spectrum disorders: is there an association with socioeconomic status and family self-education about autism?

Parent concerns prior to an assessment of autism spectrum disorder: A systematic review

LAY ABSTRACT

When a parent has concerns about their child's development, there is a lag between seeking and receiving health information. When waiting, parents may speculate about a possible diagnosis of autism spectrum disorder, but it is unclear what types of concerns might drive this speculation. To determine the types of concerns parents may have before their child is assessed, we conducted a systematic review that explored parent concerns before an autism spectrum disorder assessment. Our aim was to determine the types of concerns that might drive parents to seek medical help for their child's development. Four online databases were searched and 10 articles reporting on 9 studies matched our inclusion criteria. In these cohorts, parents reported autism spectrum disorder-specific concerns (i.e. communication, social or stereotyped behaviour concerns) or non-autism spectrum disorder-specific concerns (i.e. behaviour/temperament, developmental, medical, sensory or motor concerns). Some parents also reported on their positive and negative thoughts of a potential autism spectrum disorder diagnosis and what the diagnosis would mean to them. The most reported parental concerns before an assessment were speech and language, social and behavioural. To understand the types of concerns parents have once they seek medical help, further research into how families speculated a possible autism spectrum disorder is recommended.

School participation of autistic youths: The influence of youth, family and school factors

LAY ABSTRACT

School-aged youths have a basic human right to participate in educational and recreational activities at school. Yet, autistic youths are at high risk of being excluded from school and from school-based activities. It is important to understand how this occurs, to ensure that all autistic youths have opportunities to participate in school activities that are equal to the opportunities of their non-autistic peers. The present study investigated multiple influences on the school participation of autistic youths, including youth factors (age and autistic traits), family factors (parent education level and parental self-efficacy for supporting their child's schoolwork) and school factors (the impact of problems autistic youths experienced with the physical and social environments of school). Using an online survey, we gathered the views and experiences of the parents of 200 autistic youths aged between 4 and 16 years, in the Netherlands. We found that among the factors, only the impact of problems that autistic youths experienced with the physical environment of school was associated with their school participation. In particular, autistic youths who experienced greater difficulties with the physical environment of school had lower levels of school participation. Our findings highlight the pressing need to modify school environments to better accommodate the needs of autistic youths so that they can participate easily and comfortably.

Autism Spectrum Disorders in Calabar, Nigeria

Objectives

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is prevalent worldwide. The incidence of autism has increased worldwide. However, there is a dearth of data in sub-Saharan Africa. The study is aimed at determining the clinical and socio-developmental profile of children with ASD in a tertiary hospital in Nigeria.

Materials & Methods

This study is a six-year retrospective review of the medical records of children who presented with clinical autism diagnoses at the Department of Pediatrics, University of Calabar Teaching Hospital. Relevant data were extracted from the medical records of those who met the diagnostic criteria. Descriptive statistics were presented in proportions, percentages, and tables.

Results

Of the 1806 children with neurological disorders seen in the clinic within the study period, twenty-eight were found to have symptoms of autism based on the American Psychiatric Association›s Diagnostic and Statistical Manual V (DSM -5) criteria, giving a prevalence of 1.6%. The mean age at diagnosis was 3.8 ±1.4 (range 2 to 10) years, with a male-to-female ratio of 3:1. About two-thirds of the children diagnosed were older than three years. Seven percent of the children had siblings with autism, 53.5% of children with autism in the study had hyperactivity as comorbidity, while seizures were found in 7% of cases.

Conclusion

The prevalence of ASD among children seen in Calabar is 1.6%. Hyperactivity, mental retardation, and seizure disorders are associated comorbidities in the study. Late presentation is a common feature in this facility. Thus, increasing awareness is essential to enhance early recognition, timely diagnosis, and appropriate intervention.

Predictors of age at diagnosis in autism spectrum disorders: the use of multiple regression analyses and a classification tree on a clinical sample

The increasing prevalence of autism spectrum disorders (ASD) has led to worldwide interest in factors influencing the age of ASD diagnosis. Parents or caregivers of 237 ASD children (193 boys, 44 girls) diagnosed using the Autism Diagnostic Observation Schedule (ADOS) completed a simple descriptive questionnaire. The data were analyzed using the variable-centered multiple regression analysis and the person-centered classification tree method. We believed that the concurrent use of these two methods could produce robust results. The mean age at diagnosis was 5.8 ± 2.2 years (median 5.3 years). Younger ages for ASD diagnosis were predicted (using multiple regression analysis) by higher scores in the ADOS social domain, higher scores in ADOS restrictive and repetitive behaviors and interest domain, higher maternal education, and the shared household of parents. Using the classification tree method, the subgroup with the lowest mean age at diagnosis were children, in whom the summation of ADOS communication and social domain scores was ≥ 17, and paternal age at the delivery was ≥ 29 years. In contrast, the subgroup with the oldest mean age at diagnosis included children with summed ADOS communication and social domain scores < 17 and maternal education at the elementary school level. The severity of autism and maternal education played a significant role in both types of data analysis focused on age at diagnosis.

Age at autism spectrum disorder diagnosis and its association with child and family characteristics in a tertiary care hospital in Malaysia

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder. Despite the absence of a cure, early diagnosis and intensive early intervention can improve the outcomes. However, little is known about the median age at ASD diagnosis in Malaysia or the child/family characteristics associated with early diagnosis. Therefore, this study aimed to determine the median age at ASD diagnosis among Malaysian children presenting to the country's largest public tertiary neurodevelopmental center and to investigate the possible demographic, child, and family characteristics associated with an early age at diagnosis. Data were collected between February 2017 and February 2019 from a database maintained by the child development unit of the country's largest publicly funded tertiary hospital, containing data from an ethnically diverse population. Among Malaysian children attending the clinic, the median age at ASD diagnosis was 48 months. Early autism diagnosis (<36 months of age) was associated with increased severity of social communication and interaction impairments, coexisting intellectual impairment, children from high socioeconomic status families, and children who receive joint care from their families and a maid or babysitter. The study findings highlight the socioeconomic inequalities in the country, a lack of parental awareness of early ASD signs, and the presence of cultural influences on the age at diagnosis of ASD.

Improving early detection, diagnosis and intervention for children with autism spectrum disorder: A cross-sectional survey in China

BACKGROUND

Detection and diagnosis of autism spectrum disorder (ASD) are prerequisites for early interventions. However, few studies focused on this topic.

AIM

This study aims to characterize the timing from symptom detection to intervention in children with ASD and identify predictors of age at ASD diagnosis, presence of intervention, and the time lag between detection and diagnosis.

METHODS AND PROCEDURES

A cross-sectional survey was conducted with 303 parents (111 fathers and 192 mothers, 21-54 years) of children with ASD in Guangzhou, China.

OUTCOMES AND RESULTS

The median time from symptom observation to the first doctor visit was 3 months, while the time to ASD diagnosis averaged 6 months. Most children (76.24 %) were diagnosed within one year after detection, and 25.58 % had no intervention after diagnosis. Predictors of earlier ASD diagnosis included ASD-related symptoms identified at an older age, less serious symptoms, and initial symptoms with atypical motor development and sensory anomalies. ASD-related symptoms observed at an older age, initial symptoms with social deficits, sensory anomalies, and without language impairment, primary caregivers other than parents, families with lower income, and less social support utilization increased the odds of a time lag between detection and diagnosis. Children with fathers having lower education were less likely to receive interventions.

CONCLUSIONS AND IMPLICATIONS

Earlier ASD identification and intervention might be facilitated by health education on typical symptoms of ASD for parents with young children and incorporating ASD screening during routine health examinations for children. For children whose primary caregivers are not their parents and from lower-income families, additional support may be required for timely diagnosis after reporting ASD-related symptoms. Moreover, more intervention supports are expected for children whose fathers have lower education levels. Helping families take full advantage of support is also important for early diagnosis and intervention.

Autistic clinical profiles, age at first concern, and diagnosis among children with autism spectrum disorder

Background

To explore the relationship between autistic clinical profiles and age at first concern and diagnosis among children with autism spectrum disorder. The clinical profiles included the severity of autism, cognition, adaptability, language development, and regression.

Methods

The multivariate linear regression model was used to examine the association of diagnostic age and first-concern age with autistic clinical profiles and with further stratification analysis.

Results

A total of 801 autistic children were included. Language delay and regression were associated with earlier diagnostic age (language delay: crudeβ: -0.80, 95%CI%: -0.92--0.68; regression: crudeβ: -0.21, 95%CI%: -0.43--0.00) and the age of first concern of autistic children (language delay: crudeβ: -0.55, 95%CI%: -0.65--0.45; regression: crudeβ: -0.17, 95%CI%: -0.34--0.00). After stratification by sex, language delay tended to be more associated with the earlier diagnostic age among boys (crudeβ: -0.85, 95%CI%: -0.98--0.72) than among girls (crudeβ: -0.46, 95%CI%: -0.77--0.16). After stratification by maternal education level or family income level, language delay was most associated with the earlier diagnostic age in autistic children from families with higher socioeconomic levels.

Conclusion

Language delay, rather than other symptoms, promoted an earlier diagnostic age. Among male autistic children or children from families with higher socioeconomic levels, language delay was most significantly associated with an earlier age of diagnosis. Cognitive delay, or adaptive delay, was associated with a later age at diagnosis and presented only in autistic children from families with lower socioeconomic levels. There may be sex or socioeconomic inequality in the diagnostic age for autistic children. More publicity and public education about the diversity of autistic symptoms are urgently needed in the future, especially for low-socioeconomic families.

Predictors of an earlier diagnosis of Autism Spectrum Disorder in children and adolescents: a systematic review (1987-2017)

Autism Spectrum Disorder (ASD) is an early onset neurodevelopmental disorder in which the first signs generally emerge at approximately 12 months of age but its diagnosis is feasible only from the age of 18 months. According to the literature, the average age of diagnosis ranges from 2.7 to 7.2 years, which raises the question of factors associated with early diagnosis as a condition for early intervention. In this systematic review, we aim to identify clinical, social, and environmental factors associated with the age at which the diagnosis of ASD is confirmed in children. A literature search was performed in the Pubmed, Web of Sciences, PsycInfo, and Cochrane databases. Among the 530 publications identified, 50 were selected according to the inclusion criteria. This review focuses on studies conducted in 21 countries using data collected over a period from 1987 to 2017. These studies were published before December 31st, 2019. The results suggest that the diagnosis of ASD occurs earlier if there is a delay in social communication or the presence of intellectual disability. There is a low level of evidence concerning associations between the age at diagnosis and sex, race, parental education, or socioeconomic status and accessibility to health care. Further studies using large and well-characterized data sets are needed to simultaneously explore clinical and socio-environmental factors involved in early diagnosis.

Socioeconomic factors and autism among 16- to 30-month-old children: Evidence from a national survey of China

We examined the association of socioeconomic status with the diagnosis of autism during 16–30 months of age. Using data from a national survey in China, we included 6049 children (55.6% male) in the final analysis, among which 71 of them were clinically diagnosed with autism. Adjusted for covariates, the odds ratios for having the diagnosis of autism (2.46, 95% confidence interval: [1.32, 4.59]) among children whose mother’s level is “junior middle school or below” were significantly higher than children whose mother’s level is “college or above.” Among children of lower educated mothers, there is a higher risk of being diagnosed with autism at a young age. We recommend more support for families with a low socioeconomic status to early detect, diagnose, and manage autism.

Lay abstract

Does being born in a family of high socioeconomic status mean a higher risk of being diagnosed with autism? The evidence from the Asian area is lacking. This research was conducted among 6049 toddlers who went through an evaluation–diagnose procedure of autism and whose parents were surveyed during the national survey of China, 2016–2017. Parents reported their education levels, occupations, family income, and ethnic background. We recruited the toddlers and parents from kindergartens, communities, and hospitals in five geographically representative areas of China. On average, these toddlers were 23 months of age. We found toddlers whose mothers had less than 9 years of education (junior middle school or below) had 2.46 times the chance to get a diagnosis of autism, compared with toddlers whose mothers had more than 15 years of education (college or above). We also found that 1.17 toddlers could be diagnosed with autism in each 100 Chinese toddlers. These findings have important implications for providing support to families that have low socioeconomic status, especially families with a mother who did not complete 9 years of education. Early detection programs focused on children from low socioeconomic backgrounds should be promoted.

Relationship between cognitive ability and predictors for age at the time of autism spectrum disorder diagnosis

The rising prevalence of autism spectrum disorder (ASD) has increased awareness of the need for early diagnosis and intervention; however, not all children are diagnosed at preschool age. In the literature, findings regarding factors that may play a role in later diagnosis are inconsistent. Presence or absence of intellectual disability is a possible factor. This study aimed to identify factors associated with later diagnosis of ASD among children grouped according to low and high cognitive levels. Data of children who were previously diagnosed with ASD between 2002 and 2016 at a national autism center were analyzed. Better cognitive ability, having more siblings, and previous diagnosis of attention-deficit/hyperactivity disorder were predictors of later diagnosis among the entire cohort. Children exhibiting lower cognitive levels (LC-ASD; DQ/IQ < 70; n = 209) were diagnosed much earlier. Among this group, later ASD diagnosis was predicted by poorer adaptive behavior, more severe restricted and repetitive behaviors, and previous diagnosis of epilepsy. In the higher cognitive level group (HC-ASD; DQ/IQ ≥ 70; n = 321), familial variables and more severe social impairments were predictors of later ASD diagnosis. Clinicians should be aware of variables that may affect ASD diagnostic age among children with varying cognitive abilities.

Rural-Urban Differences in Age at Autism Diagnosis: A Multiple Model Analysis

Objective: Early recognition of autism is important, but diagnosis age varies among children. Recent studies have aimed to identify factors affecting age of diagnosis and several studies have attempted to explore geographic variation in age at diagnosis of autism. However, there is a lack of research examining geographic variations with multiple models to find whether geographic differences can be explained by risk factors such as socioeconomic status and differences in child characteristics. This study aimed to address this gap of knowledge by comparing age at diagnosis of autism between the group of people living in the center of the province and the group of people living in the rest of the province, considering potential medical and socioeconomic confounders. Method : The study population consisted of 50 autistic children born in East Azerbaijan Province between 2004 and 2016. Initially, univariate testing by ANOVA was performed to identify family and individual factors contributing to differences in age at autism diagnosis. Following this, the association between living in the center of the province and age at diagnosis in univariate and multivariate analyses was examined. Results: Results from the initial univariate analysis indicate a significant association between living in the center of province and early diagnosis. However, inclusion of possible confounders in multiple model illustrates that these geographical disparities in age at diagnosis can be explained by differences in socioeconomic and medical status. Conclusion: Although geographic variation in age at diagnosis of autism was observed, analyses show that differences in individual and family-level factors may contribute to geographic differences. In this study, most of the observed variation was accounted for by family-level factors rather than geographic policies. Findings prove that multiple strategies are required to identify targeted interventions and strategies.

Parental relationship status and age at autism spectrum disorder diagnosis of their child

LAY ABSTRACT

Autism spectrum disorder (ASD) can be diagnosed as early as 18 months of age. However, the average age at diagnosis in the United States is over 2 years later. A lot has been written about the many barriers families face when seeking a diagnosis for their child. One area of research that has received no attention is whether separation between a child's biological parents affects the age at which a child is diagnosed with ASD. This study was conducted among 561 children who were receiving an ASD diagnosis for the first time. On average, these children were 5 years of age. The study took place in an urban, outpatient specialty autism clinic in the United States. Biological parents self-reported their relationship status during the evaluation. This was categorized as either "together" (married or living together but not married) or "not together" (separated, divorced, or never married). At the time of diagnosis, most children's biological parents were together (69%). We found children of parents who were together were diagnosed 1.4 years earlier than those who were not together. These findings have important implications for providing support to families that separate early in a child's life, with the goal of reducing the age at ASD evaluation among single parents and those who have been separated from their child's other biological parent. Providing support to these families is important since earlier age at diagnosis leads to earlier intervention, which can improve long-term outcomes for the child, family, and community as a whole.

Information Avoidance and Information Seeking Among Parents of Children With ASD

We estimated the effects of information avoidance and information seeking among parents of children diagnosed with autism spectrum disorder (ASD) on age of diagnosis. An online survey was completed by 1,815 parents of children with ASD. Children of parents who self-reported that they had preferred "not to know," reported diagnoses around 3 months later than other children. Children of parents who raised concerns that they perceived as having been dealt with adequately reported diagnoses about 4 months earlier, but the children of parents who reported raising concerns repeatedly and felt that those concerns were dealt with inadequately were diagnosed over a year later. These findings suggest that failure of educational and healthcare professionals, in either substituting for parents who avoid information, or supporting those who seek information, can significantly delay the age of diagnosis.

Paving the Way toward Personalized Medicine: Current Advances and Challenges in Multi-OMICS Approach in Autism Spectrum Disorder for Biomarkers Discovery and Patient Stratification

Autism spectrum disorder (ASD) is a multifactorial neurodevelopmental disorder characterized by impairments in two main areas: social/communication skills and repetitive behavioral patterns. The prevalence of ASD has increased in the past two decades, however, it is not known whether the evident rise in ASD prevalence is due to changes in diagnostic criteria or an actual increase in ASD cases. Due to the complexity and heterogeneity of ASD, symptoms vary in severity and may be accompanied by comorbidities such as epilepsy, attention deficit hyperactivity disorder (ADHD), and gastrointestinal (GI) disorders. Identifying biomarkers of ASD is not only crucial to understanding the biological characteristics of the disorder, but also as a detection tool for its early screening. Hence, this review gives an insight into the main areas of ASD biomarker research that show promising findings. Finally, it covers success stories that highlight the importance of precision medicine and the current challenges in ASD biomarker discovery studies.

Referral, Assessment and Use of Screening Measures Related to Autism Spectrum Disorder at a Tertiary Hospital Setting

Children with developmental concerns in Australia continue to experience inequitable healthcare and service-related delays, even when diagnostic risk is identified. This study sought to explore service and demographic pathway factors leading up to autism spectrum disorder (ASD) assessment, including value of screening measures applied at triage. Following a trial of centralised intake for referred young children with suspected ASD, observational, retrospective pathway data was explored using bivariate and regression analyses. The mean age of 159 children referred with autism symptoms was 3.6 years, and 64% were diagnosed with ASD. Service allocation was associated with diagnosis, whilst screening tool results were not. Improved pathways are needed to limit wasted waiting times and direct each child to needs-based services.

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.

Pathways to a diagnosis of autism spectrum disorder in Germany: a survey of parents

BACKGROUND

Early identification of autism spectrum disorders (ASD) is a prerequisite for access to early interventions. Although parents often note developmental atypicalities during the first 2 years of life, many children with ASD are not diagnosed until school age. For parents, the long period between first parental concerns and diagnosis is often frustrating and accompanied by uncertainty and worry.

METHODS

This study retrospectively explored the trajectories of children with a confirmed ASD diagnosis during the diagnostic process, from first parental concerns about their child's development until the definite diagnosis. A survey concerning the diagnostic process was distributed to parents or legal guardians of children with ASD from three specialized ASD outpatient clinics in Germany.

RESULTS

The response rate was 36.9%, and the final sample consisted of carers of 207 affected children (83.6% male, mean age 12.9 years). The children had been diagnosed with childhood autism (55.6%), Asperger syndrome (24.2%), or atypical autism (20.3%). On average, parents had first concerns when their child was 23.4 months old, and an ASD diagnosis was established at a mean age of 78.5 months. Children with atypical autism or Asperger syndrome were diagnosed significantly later (83.9 and 98.1 months, respectively) than children with childhood autism (68.1 months). Children with an IQ < 85 were diagnosed much earlier than those with an IQ ≥ 85. On average, parents visited 3.4 different health professionals (SD = 2.4, range 1-20, median: 3.0) until their child received a definite ASD diagnosis. Overall, 38.5% of carers were satisfied with the diagnostic process.

CONCLUSIONS

In this sample of children with ASD in Germany, the time to diagnosis was higher than in the majority of other comparable studies. These results flag the need for improved forms of service provision and delivery for suspected cases of ASD in Germany.

The association between socioeconomic status and autism diagnosis in the United Kingdom for children aged 5–8 years of age: Findings from the Born in Bradford cohort

There has been recent interest in the relationship between socioeconomic status and the diagnosis of autism in children. Studies in the United States have found lower rates of autism diagnosis associated with lower socioeconomic status, while studies in other countries report no association, or the opposite. This article aims to contribute to the understanding of this relationship in the United Kingdom. Using data from the Born in Bradford cohort, comprising 13,857 children born between 2007 and 2011, it was found that children of mothers educated to A-level or above had twice the rate of autism diagnosis, 1.5% of children (95% confidence interval: 1.1%, 1.9%) compared to children of mothers with lower levels of education status 0.7% (95% confidence interval: 0.5%, 0.9%). No statistically significant relationship between income status or neighbourhood material deprivation was found after controlling for mothers education status. The results suggest a substantial level of underdiagnosis for children of lower education status mothers, though further research is required to determine the extent to which this is replicated across the United Kingdom. Tackling inequalities in autism diagnosis will require action, which could include increased education, awareness, further exploration of the usefulness of screening programmes and the provision of more accessible support services.