Maria Massolo

Increased Risk of Adverse Neurological Development for Late Preterm Infants

OBJECTIVE To assess the risks of moderate prematurity for cerebral palsy (CP), developmental delay/mental retardation (DD/MR), and seizure disorders in early childhood. STUDY DESIGN Retrospective cohort study using hospitalization and outpatient databases from the Northern California Kaiser Permanente Medical Care Program. Data covered 141 321 children > or =30 weeks born between Jan 1, 2000, and June 30, 2004, with follow-up through June 30, 2005. Presence of CP, DD/MR, and seizures was based on International Classification of Diseases, Ninth Revision codes identified in the encounter data. Separate Cox proportional hazard models were used for each of the outcomes, with crude and adjusted hazard ratios calculated for each gestational age group. RESULTS Decreasing gestational age was associated with increased incidence of CP and DD/MR, even for those born at 34 to 36 weeks gestation. Children born late preterm were >3 times as likely (hazard ratio, 3.39; 95% CI, 2.54-4.52) as children born at term to be diagnosed with CP. A modest association with DD/MR was found for children born at 34 to 36 weeks (hazard ratio, 1.25; 95% CI, 1.01-1.54), but not for children in whom seizures were diagnosed. CONCLUSIONS Prematurity is associated with long-term neurodevelopmental consequences, with risks increasing as gestation decreases, even in infants born at 34 to 36 weeks.

The health status of adults on the autism spectrum

Compared to the general pediatric population, children with autism have higher rates of co-occurring medical and psychiatric illnesses, yet very little is known about the general health status of adults with autism. The objective of this study was to describe the frequency of psychiatric and medical conditions among a large, diverse, insured population of adults with autism in the United States. Participants were adult members of Kaiser Permanente Northern California enrolled from 2008 to 2012. Autism spectrum disorder cases (N = 1507) were adults with autism spectrum disorder diagnoses (International Classification of Diseases-9-Clinical Modification codes 299.0, 299.8, 299.9) recorded in medical records on at least two separate occasions. Controls (N = 15,070) were adults without any autism spectrum disorder diagnoses sampled at a 10:1 ratio and frequency matched to cases on sex and age. Adults with autism had significantly increased rates of all major psychiatric disorders including depression, anxiety, bipolar disorder, obsessive–compulsive disorder, schizophrenia, and suicide attempts. Nearly all medical conditions were significantly more common in adults with autism, including immune conditions, gastrointestinal and sleep disorders, seizure, obesity, dyslipidemia, hypertension, and diabetes. Rarer conditions, such as stroke and Parkinson’s disease, were also significantly more common among adults with autism. Future research is needed to understand the social, healthcare access, and biological factors underlying these observations.

Infant siblings and the investigation of autism risk factors

Infant sibling studies have been at the vanguard of autism spectrum disorders (ASD) research over the past decade, providing important new knowledge about the earliest emerging signs of ASD and expanding our understanding of the developmental course of this complex disorder. Studies focused on siblings of children with ASD also have unrealized potential for contributing to ASD etiologic research. Moving targeted time of enrollment back from infancy toward conception creates tremendous opportunities for optimally studying risk factors and risk biomarkers during the pre-, peri- and neonatal periods. By doing so, a traditional sibling study, which already incorporates close developmental follow-up of at-risk infants through the third year of life, is essentially reconfigured as an enriched-risk pregnancy cohort study. This review considers the enriched-risk pregnancy cohort approach of studying infant siblings in the context of current thinking on ASD etiologic mechanisms. It then discusses the key features of this approach and provides a description of the design and implementation strategy of one major ASD enriched-risk pregnancy cohort study: the Early Autism Risk Longitudinal Investigation (EARLI).

Risk Factors for Developing Apnea After Immunization in the Neonatal Intensive Care Unit

OBJECTIVES. Among hospitalized NICU infants, preimmunization apnea is a well-recognized predictor of postimmunization apnea. However, predictors for postimmunization apnea among NICU infants without preimmunization apnea have not been investigated. METHODS. Using a large NICU database in the Northern California Kaiser Permanente Medical Care Program, we abstracted NICU charts of infants who were hospitalized for ≥53 days and who were also immunized, capturing preimmunization (24 hours before immunization) and postimmunization (48 hours after immunization) events. We assessed factors associated with postimmunization apnea by using multivariate logistic regression. RESULTS. Of 16 146 infants admitted to the NICU, 557 received ≥1 vaccine and 497 met the criteria for study entry. All infants with preimmunization apnea (n = 27) and all except 3 infants with postimmunization apnea (n = 65) had gestational ages of <31 weeks. Multivariate analyses revealed preimmunization apnea as the most important predictor of postimmunization apnea, although higher 12-hour Score for Neonatal Acute Physiology II and age of <67 days (mean cohort age) were also associated. Multivariate analysis exclusively among infants without preimmunization apnea similarly found elevated Score for Neonatal Acute Physiology II, age of <67 days, and weight of <2000 g to be associated with postimmunization apnea. Forty-nine infants without preimmunization apnea and with ≥1 apnea predictor were discharged within 48 hours after immunization; 2 were subsequently readmitted because of apnea. CONCLUSIONS. For infants in the NICU without apnea during the 24 hours immediately before immunization, younger age, smaller size, and more severe illness at birth are important predictors of postimmunization apnea.

Health Services Utilization Among Children With and Without Autism Spectrum Disorders

Using data from multiple health systems (2009–2010) and the largest sample to date, this study compares health services use among youth with and without an autism spectrum disorder (ASD)—including preventive services not previously studied. To examine these differences, we estimated logistic and count data models, controlling for demographic characteristics, comorbid physical health, and mental health conditions. Results indicated that youth with an ASD had greater health care use in many categories, but were less likely to receive important preventive services including flu shots and other vaccinations. An improved understanding of the overall patterns of health care use among this population could enable health systems to facilitate the receipt of appropriate and effective health care.

Psychiatric and Medical Conditions in Transition-Aged Individuals With ASD

BACKGROUND AND OBJECTIVES: Children with autism spectrum disorder (ASD) have a variety of medical and psychiatric conditions and an increased use of health care services. There is limited information about the prevalence of psychiatric and medical conditions in adolescents and young adults with ASD. Our objective was to describe the frequency of medical and psychiatric conditions in a large population of diverse, insured transition-aged individuals with ASD. METHODS: Participants included Kaiser Permanente Northern California members who were enrolled from 2013 to 2015 and who were 14 to 25 years old. Individuals with ASD (n = 4123) were compared with peers with attention-deficit/hyperactivity disorder (n = 20 615), diabetes mellitus (n = 2156), and typical controls with neither condition (n = 20 615). RESULTS: Over one-third (34%) of individuals with ASD had a co-occurring psychiatric condition; the most commonly reported medical conditions included infections (42%), obesity (25%), neurologic conditions (18%), allergy and/or immunologic conditions (16%), musculoskeletal conditions (15%), and gastrointestinal (11%) conditions. After controlling for sex, age, race, and duration of Kaiser Permanente Northern California membership, most psychiatric conditions were significantly more common in the ASD group than in each comparison group, and most medical conditions were significantly more common in the ASD group than in the attention-deficit/hyperactivity disorder and typical control groups but were similar to or significantly less common than the diabetes mellitus group. CONCLUSIONS: Although more research is needed to identify factors contributing to this excess burden of disease, there is a pressing need for all clinicians to approach ASD as a chronic health condition requiring regular follow-up and routine screening and treatment of medical and psychiatric issues.

PS1-13: Variation in the Incidence and Prevalence of Autism from Multiple Health Systems: Findings from the Mental Health Research Network Autism Registry Study

Background/Aims Autism spectrum disorders (ASD) are characterized by impairments in social interaction and communication, as well as restricted, stereotyped interests and behaviors. A recent study found that approximately 1 in 88 children in the U.S. were diagnosed with an ASD and that prevalence varied widely among different demographic groups. The goals of this study were to obtain accurate prevalence and incidence statistics for ASD across several large, diverse health systems and to describe the variation of these statistics across demographic factors. Methods All members within the five participating health systems born between January 1, 1993 and December 31, 2008 with electronic claims, enrollment, or medical record information were included in the study. Information on member demographics and ASD subtypes were collected from earliest available records at each site through the end of December 31, 2010. Individuals with an ASD diagnosis from an ASD specialist or two or more ASD diagnoses from non-specialists were defined as valid cases. Results A preliminary examination of data from one site (N = 1,271,823) found 10,114 individuals <18 years ever diagnosed with an ASD. Of those 10,114 ASD cases, 8,085 met the validation criteria and were included in final analyses. Prevalence of all ASDs in children ≤8 years old was 1.1/1000 in 2001 (1 in 909 children) and increased steadily to 7.1/1000 in 2010 (1 in 141 children). Prevalence specifically for autistic disorder (AD), a more severe subtype, in children ≤8 years old was 0.3/1000 in 2001 and increased to 1.9/1000 in 2010. Similar secular increases were noted for incidence. Prevalence and incidence varied greatly among demographic groups. Prevalence of all ASDs in 2010 was 8.4/1000 among Whites, 7.1/1000 among Blacks, and 10.6/1000 among Asians. Prevalence of ASDs among females was lower than among males in all years (2010 males: 11.2/1000, 2010 females: 2.8/1000). Conclusions This study provides up-to-date prevalence and incidence information from a group of large, diverse, community-based settings. Incidence and prevalence differed across racial groups and sex status. Strong increasing trends in the diagnosis of ASDs in general, as well as the AD subtype, were observed.

PS1-14: Health-Related Quality of Life in Children with Autism Spectrum Disorders: Findings from the Mental Health Research Network Autism Registry Web Survey

Background/Aims Approximately 1 in 88 children in the U.S. is diagnosed with Autism Spectrum Disorder (ASD). ASD is a complex disorder characterized by impairment in social skills, communication, and cognitive and behavioral functioning. In order for policy makers and clinical managers to evaluate new approaches to treating and managing ASD, they need brief comprehensive outcome measures. One approach that could be useful in this context is measurement of health-related quality of life (HR-QOL), which provides a comprehensive picture of health status including an individual’s psychosocial, emotional, and physical wellbeing. This comprehensive approach is particularly important in conditions such as ASD that have multiple impacts on a person’s health. Few previous studies have examined HR-QOL in persons with ASD, and most of these studies have used small samples. The purpose of this analysis is to examine HR-QOL in a group of geographically- and racially/ethnically-diverse children with ASD who are enrolled in the Mental Health Research Network (MHRN) Autism Registry. Methods A Web-based survey of parents of children with ASD was implemented at four MHRN Autism Registry sites, including children’s HR-QOL, measured by the Pediatric Quality of Life Inventory (PedsQLTM). The PedsQLTM provides an overall score, as well as subscales for important domains including physical health, psychosocial health, emotional functioning, social functioning, and school functioning. Results To date, recruitment letters have been mailed to approximately 8800 parents and 800 surveys have been completed. Preliminary analyses of respondents indicate that HR-QOL is lower in children with ASD compared to national norms. We will present the final results from the survey, which will conclude in November 2012. The presentation will examine the overall scores, scores on subscales, and scores by subgroup (e.g., age, gender, race) and will compare these scores to national norms. Conclusions We successfully implemented a Web-based survey of parents of children with ASD across four MHRN sites. With 800 completed surveys (recruitment will continue through November 2012), this is the largest known population-based survey on children with ASD to date. The current study will help to confirm results from smaller samples and will allow for more refined analyses of subgroups.