Thursday, November 30, 2023
| Site | Surveillance area description | Denominator | No. aged 4 yrs with ASD | ASD prevalence (95% CI)† | % Who had an ASD diagnostic statement | % Who had ASD special education eligibility | % Who had ASD ICD code |
|---|---|---|---|---|---|---|---|
| Arizona | Part of one county in metropolitan Phoenix | 13,349§ | 209 | 15.7 (13.7–17.9) | 75.6 | 11.0 | 63.2 |
| Arkansas | 21 counties in central Arkansas | 15,150 | 245 | 16.2 (14.3–18.3) | 95.5 | 36.3 | 84.5 |
| California | Part of one county in metropolitan San Diego | 16,719§ | 776 | 46.4 (43.3–49.7) | 85.8 | 69.7 | 88.3 |
| Georgia | Two counties in metropolitan Atlanta | 21,985 | 384 | 17.5 (15.8–19.3) | 77.3 | 41.1 | 71.1 |
| Maryland | Five counties in suburban Baltimore | 20,745 | 352 | 17.0 (15.3–18.8) | 90.3 | 43.2 | 72.4 |
| Minnesota | Parts of three counties in the Twin Cities metropolitan area | 16,326§ | 305 | 18.7 (16.7–20.9) | 54.1 | 75.1 | 22.0 |
| Missouri | Five counties in metropolitan St. Louis | 24,476 | 456 | 18.6 (17.0–20.4) | 95.0 | 17.5 | 92.5 |
| New Jersey | Two counties in the New York metropolitan area | 19,120 | 473 | 24.7 (22.6–27.0) | 98.3 | 9.3 | 76.7 |
| Tennessee | 11 counties in middle Tennessee | 26,474 | 737 | 27.8 (25.9–29.9) | 71.0 | 32.8 | 92.7 |
| Utah | Three counties in northern Utah | 24,330 | 308 | 12.7 (11.3–14.1) | 79.9 | 25.0 | 81.8 |
| Wisconsin | Eight counties in southeastern Wisconsin | 28,852 | 651 | 22.6 (20.9–24.3) | 65.1 | 35.3 | 84.0 |
| Total | 227,526 | 4,896 | 21.5 (20.9–22.1) | 80.2 | 38.1 | 79.4 | |
Table 1. Prevalence* of autism spectrum disorder among children aged 4 years and percentage of children who had an autism spectrum disorder diagnosis, special education eligibility, or an International Classification of Diseases code — Autism and Developmental Disabilities Monitoring Network, 11 sites, 2020
Abbreviations: ASD = autism spectrum disorder; ICD = International Classification of Diseases.
*Per 1,000 children aged 4 years.
†95% CIs were calculated using the Wilson score method.
§Denominator excludes school districts that were not included in the surveillance area, calculated from National Center for Education Statistics enrollment counts of kindergarteners during the 2020–21 school year.
| Site | Male ASD prevalence (95% CI)§ | Female ASD prevalence (95% CI) | Male-to-female prevalence ratio (95% CI)¶ |
|---|---|---|---|
| Arizona | 24.2 (20.8–28.1) | 6.9 (5.1–9.2) | 3.5 (2.5–4.9) |
| Arkansas | 24.9 (21.7–28.6) | 6.9 (5.2–9.0) | 3.6 (2.7–4.9) |
| California | 71.7 (66.4–77.4) | 20.5 (17.6–23.7) | 3.5 (3.0–4.1) |
| Georgia | 25.5 (22.7–28.6) | 8.9 (7.3–10.9) | 2.9 (2.3–3.6) |
| Maryland | 26.4 (23.5–29.6) | 7.3 (5.8–9.1) | 3.6 (2.8–4.7) |
| Minnesota | 29.7 (26.3–33.6) | 7.3 (5.7–9.4) | 4.1 (3.1–5.4) |
| Missouri | 26.8 (24.1–29.8) | 10.2 (8.6–12.2) | 2.6 (2.1–3.2) |
| New Jersey | 35.0 (31.5–38.9) | 14.1 (11.9–16.7) | 2.5 (2.0–3.0) |
| Tennessee | 41.1 (37.8–44.5) | 14.3 (12.4–16.4) | 2.9 (2.4–3.4) |
| Utah | 19.5 (17.3–22.1) | 5.5 (4.3–7.0) | 3.6 (2.7–4.7) |
| Wisconsin | 33.4 (30.6–36.4) | 11.2 (9.6–13.1) | 3.0 (2.5–3.6) |
| Total | 32.3 (31.3–33.3) | 10.4 (9.8–11.0) | 3.1 (2.9–3.3) |
Table 2. Prevalence* of autism spectrum disorder among children aged 4 years, by sex† — Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020
Abbreviation: ASD = autism spectrum disorder.
*Per 1,000 children aged 4 years.
†Four children were missing sex information.
§95% CIs were calculated using the Wilson score method.
¶Prevalence was significantly higher among males than females at all sites (95% CI excludes 1.0).
| Site | ASD prevalence (95% CI)§ | Prevalence ratio (95% CI) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| White | Black | Hispanic | Asian/Pacific Islander | Multiracial | Black to White | Hispanic to White | Asian/Pacific Islander to White | Multiracial to White | |
| Arizona | 18.4 (15.0–22.5) | 15.0 (8.9–25.0) | 14.7 (12.0–18.2) | — ¶ | — | 0.8 (0.5–1.4) | 0.8 (0.6–1.1) | — | — |
| Arkansas | 13.6 (11.4–16.2) | 22.4 (18.1–27.8) | 17.6 (12.1–25.5) | — | 15.8 (8.8–28.1) | 1.6 (1.2–2.2)** | 1.3 (0.9–1.9) | — | 1.2 (0.6–2.1) |
| California | 31.0 (26.2–36.6) | 54.3 (42.6–68.8) | 52.8 (48.1–57.9) | 45.5 (37.1–55.6) | 52.4 (41.7–65.7) | 1.8 (1.3–2.3)** | 1.7 (1.4–2.1)** | 1.5 (1.1–1.9)** | 1.7 (1.3–2.2)** |
| Georgia | 8.1 (6.0–10.7) | 21.9 (19.3–24.9) | 16.1 (12.0–21.7) | 17.4 (12.5–24.3) | 20.8 (13.2–32.7) | 2.7 (2.0–3.7)** | 2.0 (1.3–3.0)** | 2.2 (1.4–3.3)** | 2.6 (1.5–4.4)** |
| Maryland | 11.9 (10.0–14.1) | 27.6 (23.3–32.5) | 12.9 (8.9–18.6) | 22.3 (16.5–30.2) | 17.0 (11.3–25.7) | 2.3 (1.8–3.0)** | 1.1 (0.7–1.6) | 1.9 (1.3–2.7)** | 1.4 (0.9–2.2) |
| Minnesota | 13.1 (10.7–16.1) | 23.4 (19.0–28.7) | 24.1 (17.8–32.4) | 18.9 (14.4–25.0) | 19.0 (12.4–28.8) | 1.8 (1.3–2.4)** | 1.8 (1.3–2.6)** | 1.4 (1.0–2.0)** | 1.4 (0.9–2.3) |
| Missouri | 17.3 (15.4–19.5) | 22.4 (18.8–26.5) | 15.8 (10.1–24.5) | 26.1 (17.6–38.5) | 9.7 (5.6–16.9) | 1.3 (1.0–1.6)** | 0.9 (0.6–1.4) | 1.5 (1.0–2.3)** | 0.6 (0.3–1.0) |
| New Jersey | 16.4 (13.3–20.3) | 23.8 (20.1–28.1) | 31.7 (27.8–36.1) | 17.6 (11.4–27.0) | — | 1.4 (1.1–1.9)** | 1.9 (1.5–2.5)** | 1.1 (0.7–1.7) | — |
| Tennessee | 23.8 (21.5–26.3) | 34.6 (29.6–40.3) | 31.4 (26.3–37.5) | 28.7 (19.7–41.8) | 17.5 (12.0–25.5) | 1.5 (1.2–1.7)** | 1.3 (1.1–1.6)** | 1.2 (0.8–1.8) | 0.7 (0.5–1.1) |
| Utah | 11.7 (10.2–13.5) | — | 14.9 (11.9–18.5) | 16.3 (10.4–25.2) | — | — | 1.3 (1.0–1.6)** | 1.4 (0.9–2.2) | — |
| Wisconsin | 16.5 (14.6–18.6) | 27.5 (23.4–32.2) | 36.9 (32.0–42.6) | 22.5 (16.3–31.0) | 17.1 (11.6–25.1) | 1.7 (1.4–2.0)** | 2.2 (1.9–2.7)** | 1.4 (1.0–1.9)** | 1.0 (0.7–1.6) |
| Total†† | 16.3 (15.5–17.0) | 25.3 (23.9–26.8) | 28.7 (27.2–30.3) | 23.5 (21.2–26.1) | 19.3 (17.0–21.9) | 1.6 (1.4–1.7)** | 1.8 (1.6–1.9)** | 1.4 (1.3–1.6)** | 1.2 (1.0–1.4)** |
Table 3. Prevalence* of autism spectrum disorder among children aged 4 years, by race and ethnicity† — Autism and Developmental Disabilities Monitoring Network, 11 sites, 2020
Per 1,000 children aged 4 years.
†Persons of Hispanic origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic. Excludes children of other or unknown race (n = 94).
§95% CIs were calculated using the Wilson score method.
¶Dashes indicate suppressed estimate (relative SE ≥30% estimate or ratio involving at least one suppressed estimate).
**Significant prevalence ratio (95% CI excludes 1.0).
††All site estimates for American Indian/Alaska Native (AI/AN) children were unstable (relative SE ≥30% estimate) and therefore not reported in the table. Overall AI/AN prevalence was 11.1 (95% CI = 6.2–19.7). Prevalence among AI/AN children was similar to White children (White-to-AI/AN prevalence ratio = 1.5; 95% CI = 0.8–2.6), but ASD prevalence was higher among Black (Black-to-AI/AN prevalence ratio = 2.3; 95% CI = 1.3–4.1), Hispanic (Hispanic-to-AI/AN prevalence ratio = 2.6; 95% CI = 1.4–4.6), A/PI (A/PI-to-AI/AN prevalence ratio = 2.1; 95% CI = 1.2–3.8), and multiracial (multiracial-to-AI/AN prevalence ratio = 1.7; 95% CI = 1.0–3.2) children.
| Site/Characteristic | With intellectual disability information No. (%)* | With co-occurring intellectual disability No. (%)† |
|---|---|---|
| Arizona | 172 (82.3) | 70 (40.7) |
| Arkansas | 220 (89.8) | 148 (67.3) |
| California | 594 (76.5) | 147 (24.7) |
| Georgia | 273 (71.1) | 155 (56.8) |
| Maryland | 226 (64.2) | 132 (58.4) |
| Minnesota | 229 (75.1) | 143 (62.4) |
| Missouri | 185 (40.6) | 93 (50.3) |
| New Jersey | 228 (48.2) | 135 (59.2) |
| Tennessee | 327 (44.4) | 182 (55.7) |
| Utah | 148 (48.1) | 64 (43.2) |
| Wisconsin | 251 (38.6) | 115 (45.8) |
| Total | 2,853 (58.3) | 1,384 (48.5) |
| Sex§ | ||
| Female | 654 (56.4) | 302 (46.2) |
| Male | 2,198 (58.9) | 1,081 (49.2) |
| Race and ethnicity¶ | ||
| Asian/Pacific Islander | 231 (67.0) | 114 (49.4) |
| Black | 664 (56.4) | 416 (62.7) |
| White | 1,018 (57.1) | 438 (43.0) |
| Multiracial | 163 (71.2) | 66 (40.5) |
| Hispanic | 748 (59.5) | 334 (44.7) |
Table 4. Presence of co-occurring intellectual disability among children aged 4 years with autism spectrum disorder and available intellectual disability information, by site and selected characteristics — Autism and Developmental Disabilities Monitoring Network, 11 sites, 2020
*Chi-square p values for significant comparisons for presence of intellectual disability information: White to Asian/Pacific Islander, White to multiracial, Black to Asian/Pacific Islander, Black to multiracial: p<0.01.
†Chi-square p values for significant comparisons for presence of co-occurring intellectual disability: White to Black, Black to Hispanic, Black to Asian/Pacific Islander, and Black to multiracial: p<0.01.
§One child with intellectual disability information was missing sex information
¶Persons of Hispanic origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic. Excludes children of other or unknown race; American Indian or Alaska Native not shown because of small numbers.
| Site/Characteristic | No. with evaluation | Evaluated by age 36 mos No. (%)* |
|---|---|---|
| Arizona | 191 | 160 (83.8) |
| Arkansas | 245 | 215 (87.8) |
| California | 770 | 648 (84.2) |
| Georgia | 341 | 269 (78.9) |
| Maryland | 342 | 284 (83.0) |
| Minnesota | 300 | 227 (75.7) |
| Missouri | 456 | 343 (75.2) |
| New Jersey | 472 | 377 (79.9) |
| Tennessee | 649 | 433 (66.7) |
| Utah | 291 | 221 (75.9) |
| Wisconsin | 503 | 378 (75.1) |
| Total | 4,560 | 3,555 (78.0) |
| Sex† | ||
| Female | 1,082 | 842 (77.8) |
| Male | 3,477 | 2,712 (78.0) |
| Race and ethnicity§ | ||
| Asian/Pacific Islander | 326 | 246 (75.5) |
| Black | 1,087 | 825 (75.9) |
| White | 1,653 | 1,307 (79.1) |
| Multiracial | 218 | 174 (79.8) |
| Hispanic | 1,182 | 943 (79.8) |
| Co-occurring intellectual disability | ||
| Intellectual disability confirmed | 1,372 | 1,131 (82.4) |
| No intellectual disability | 1,452 | 1,235 (85.1) |
| Unknown | 1,736 | 1,189 (68.5) |
Table 5. Percentage of children aged 4 years with autism spectrum disorder who had earliest recorded evaluation by age 36 months, by site and selected characteristics — Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020
*Chi-square p values for significant comparisons: Black to Hispanic: p = 0.03, confirmed intellectual disability to unknown, and no intellectual disability to unknown: p<0.01.
†One child with an evaluation was missing sex information.
§Persons of Hispanic origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic. Excludes children of other or unknown race; American Indian or Alaska Native not shown because of small numbers.
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Problem/Condition: Autism spectrum disorder (ASD).
Period Covered: 2020.
Description of System: The Autism and Developmental Disabilities Monitoring Network is an active surveillance program that estimates prevalence and characteristics of ASD and monitors timing of ASD identification among children aged 4 and 8 years. In 2020, a total of 11 sites (located in Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin) conducted surveillance of ASD among children aged 4 and 8 years and suspected ASD among children aged 4 years. Surveillance included children who lived in the surveillance area at any time during 2020. Children were classified as having ASD if they ever received 1) an ASD diagnostic statement in an evaluation, 2) a special education classification of autism (eligibility), or 3) an ASD International Classification of Diseases (ICD) code (revisions 9 or 10). Children aged 4 years were classified as having suspected ASD if they did not meet the case definition for ASD but had a documented qualified professional's statement indicating a suspicion of ASD. This report focuses on children aged 4 years in 2020 compared with children aged 8 years in 2020.
Results: For 2020, ASD prevalence among children aged 4 years varied across sites, from 12.7 per 1,000 children in Utah to 46.4 in California. The overall prevalence was 21.5 and was higher among boys than girls at every site. Compared with non-Hispanic White children, ASD prevalence was 1.8 times as high among Hispanic, 1.6 times as high among non-Hispanic Black, 1.4 times as high among Asian or Pacific Islander, and 1.2 times as high among multiracial children. Among the 58.3% of children aged 4 years with ASD and information on intellectual ability, 48.5% had an IQ score of ≤70 on their most recent IQ test or an examiner's statement of intellectual disability. Among children with a documented developmental evaluation, 78.0% were evaluated by age 36 months. Children aged 4 years had a higher cumulative incidence of ASD diagnosis or eligibility by age 48 months compared with children aged 8 years at all sites; risk ratios ranged from 1.3 in New Jersey and Utah to 2.0 in Tennessee. In the 6 months before the March 2020 COVID-19 pandemic declaration by the World Health Organization, there were 1,593 more evaluations and 1.89 more ASD identifications per 1,000 children aged 4 years than children aged 8 years received 4 years earlier. After the COVID-19 pandemic declaration, this pattern reversed: in the 6 months after pandemic onset, there were 217 fewer evaluations and 0.26 fewer identifications per 1,000 children aged 4 years than children aged 8 years received 4 years earlier. Patterns of evaluation and identification varied among sites, but there was not recovery to pre-COVID-19 pandemic levels by the end of 2020 at most sites or overall. For 2020, prevalence of suspected ASD ranged from 0.5 (California) to 10.4 (Arkansas) per 1,000 children aged 4 years, with an increase from 2018 at five sites (Arizona, Arkansas, Maryland, New Jersey, and Utah). Demographic and cognitive characteristics of children aged 4 years with suspected ASD were similar to children aged 4 years with ASD.
Interpretation: A wide range of prevalence of ASD by age 4 years was observed, suggesting differences in early ASD identification practices among communities. At all sites, cumulative incidence of ASD by age 48 months among children aged 4 years was higher compared with children aged 8 years in 2020, indicating improvements in early identification of ASD. Higher numbers of evaluations and rates of identification were evident among children aged 4 years until the COVID-19 pandemic onset in 2020. Sustained lower levels of ASD evaluations and identification seen at a majority of sites after the pandemic onset could indicate disruptions in typical practices in evaluations and identification for health service providers and schools through the end of 2020. Sites with more recovery could indicate successful strategies to mitigate service interruption, such as pivoting to telehealth approaches for evaluation.
Public Health Action: From 2016 through February of 2020, ASD evaluation and identification among the cohort of children aged 4 years was outpacing ASD evaluation and identification 4 years earlier (from 2012 until March 2016) among the cohort of children aged 8 years in 2020 . From 2016 to March 2020, ASD evaluation and identification among the cohort of children aged 4 years was outpacing that among children aged 8 years in 2020 from 2012 until March 2016. The disruptions in evaluation that coincided with the start of the COVID-19 pandemic and the increase in prevalence of suspected ASD in 2020 could have led to delays in ASD identification and interventions. Communities could evaluate the impact of these disruptions as children in affected cohorts age and consider strategies to mitigate service disruptions caused by future public health emergencies.
Autism spectrum disorder (ASD) is a developmental disability characterized by deficits in social interaction or communication and the presence of restricted interests or repetitive behaviors. The American Academy of Pediatrics recommends that pediatric care providers screen all children for ASD at ages 18 and 24 months in addition to regular developmental surveillance.[1] Early developmental screening and receipt of services for children with ASD also are core national objectives for Healthy People 2030.[2] During early childhood, ongoing neurodevelopmental processes present the opportunity to optimize children's ability to develop language and social skills.[3–5] Early ASD identification is important to ensure children have access to services they might need to support development of these skills.
The Autism and Developmental Disabilities Monitoring (ADDM) Network has reported biennial ASD estimates since 2000 and began tracking ASD identification among children aged 4 years in a subset of sites in 2010.[6] In 2018, surveillance among this age group expanded to the full ADDM Network. New patterns in ASD prevalence by race and ethnicity emerged, with children from groups with historically lower prevalence, including non-Hispanic Black and Hispanic children, and children in lower socioeconomic status (SES) neighborhoods having the highest prevalence.[7] Since 2016, comparisons with children aged 8 years have shown more early identification of ASD by age 48 months among younger cohorts.[7,8]
The 2020 surveillance year includes the COVID-19 pandemic declaration by the World Health Organization in March 2020 (https://www.who.int/europe/emergencies/situations/covid-19) and ensuing shutdowns in the United States. The Act Early Response to COVID-19 project performed a rapid needs assessment in 2020, surveying key partners from early childhood programs and systems in 43 U.S. states and territories. Overall, 91% of the 349 participants reported the COVID-19 pandemic had "highly impacted" early identification of children with developmental delays and disabilities.[9] Forty-eight percent of these participants reported during fall 2020 that the number of children served by early childhood programs and systems had decreased since the start of the pandemic. The ADDM Network is uniquely positioned to provide population-based measures that can show disruptions to timely evaluation and identification of ASD.
This report provides data on early ASD identification among children aged 4 years in 11 U.S. communities, including prevalence and characteristics of children with ASD and suspected ASD in 2020, and comparisons with children aged 8 years to show patterns in identification and emergence of possible impacts of the COVID-19 pandemic. These data can be used for ongoing monitoring of trends and to support efforts to ensure early and equitable identification of children with ASD.
