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Cited by 223Autism Spectrum Disorder ResearchChild Nutrition and Feeding IssuesFamily and Disability Support Research

Early Identification of Autism Spectrum Disorder Among Children Aged 4 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2020

Open access
Shaw, Kelly A., Bilder, Deborah A., McArthur, Dedria, Williams, Ashley Robinson, Amoakohene, Esther, Bakian, Amanda V., Durkin, Maureen S., Fitzgerald, Robert T. +29 more·2023·MMWR. Surveillance Summaries
DOI 10.15585/mmwr.ss7201a1PMC PMC10042615
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Abstract

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 fut

AI snapshot

Written from the paper’s full text.

TL;DR

In 2020, Autism and Developmental Disabilities Monitoring Network surveillance across 11 U.S. sites estimated ASD prevalence among children aged 4 years at 21.5 per 1,000, with wide site variation and higher prevalence among boys and several racial/ethnic minority groups. Early identification by age 48 months was higher among children aged 4 years than among children aged 8 years, but evaluations and identifications fell after the March 2020 COVID-19 pandemic declaration and had not fully recovered by the end of 2020 at most sites.

Key findings

  • Overall ASD prevalence among children aged 4 years was 21.5 per 1,000 (1 in 46), ranging from 12.7 per 1,000 in Utah to 46.4 in California. Prevalence was 32.3 per 1,000 among boys versus 10.4 among girls (male-to-female ratio 3.1).
  • By race and ethnicity, prevalence was highest among Hispanic children (28.7 per 1,000), followed by Black (25.3), Asian/Pacific Islander (23.5), multiracial (19.3), White (16.3), and American Indian/Alaska Native children (11.1). Compared with White children, prevalence was 1.8 times as high among Hispanic, 1.6 times as high among Black, 1.4 times as high among Asian/Pacific Islander, and 1.2 times as high among multiracial children.
  • Among the 58.3% of children aged 4 years with ASD who had intellectual ability information, 48.5% had an IQ score ≤70 or an examiner’s statement of intellectual disability. Among children with a documented developmental evaluation, 78.0% were evaluated by age 36 months.
  • Cumulative incidence of ASD diagnosis or eligibility by age 48 months was 17.5 per 1,000 among children aged 4 years versus 11.2 among children aged 8 years (1.6 times higher), with site risk ratios from 1.3 in New Jersey and Utah to 2.0 in Tennessee. In the 6 months before the March 2020 pandemic declaration, there were 1,593 more evaluations and 1.89 more ASD identifications per 1,000 children aged 4 years than children aged 8 years had 4 years earlier; in the 6 months after, there were 217 fewer evaluations and 0.26 fewer identifications per 1,000. Suspected ASD prevalence ranged from 0.5 per 1,000 in California to 10.4 in Arkansas and increased from 2018 at five sites.

Methods

  • Active surveillance was conducted in 11 sites in Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin among children aged 4 and 8 years in 2020. Children met the ASD case definition if records documented an ASD diagnostic statement, ASD special education eligibility, or an ASD ICD-9/ICD-10 code; suspected ASD was defined as a qualified professional’s statement of suspicion without meeting the ASD case definition.
  • Data came from health and education records, with denominators from U.S. Census 2021 county-level postcensal population estimates for 2020, adjusted for subcounty school districts at three sites using public school enrollment counts. Analyses calculated prevalence, prevalence ratios, cumulative incidence, and risk ratios using the Wilson score method for 95% CIs, with Mantel-Haenszel, chi-square, or Fisher tests for selected comparisons; R version 4.2.0 was used.
  • To assess COVID-19 impact, monthly counts of evaluations and earliest identification for children aged 4 years in 2016–2020 were compared with the same age windows for children aged 8 years in 2012–2016.

Limitations

  • The paper states four limitations: surveillance area populations are not necessarily generalizable to entire states or the United States; data quality depends on availability and completeness of records; sites or study areas could change between study years, complicating comparisons over time; and the surveillance case definition of intellectual disability is not the same as a clinical diagnosis, with IQ measurements in young children potentially unstable.
  • Evident from the text: intellectual ability information was available for only 58.3% of children aged 4 years with ASD, so co-occurring intellectual disability estimates are based on a subset. Also, comparisons between children with ASD and suspected ASD were among children seen for a developmental evaluation, so disparities in receiving evaluations could still exist.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.15585/mmwr.ss7201a1

Cites

23 of 23 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 28 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The overall ASD prevalence among children aged 4 years across the 11 ADDM Network sites in 2020 was 21.5 per 1,000.

    “The overall prevalence was 21.5 and was higher among boys than girls at every site.”
    • Also stated in: § Prevalence and Characteristics of Children Aged 4 Years with ASD · plain
      “ASD prevalence in the 11 sites combined was 21.5 per 1,000 (one in 46) children aged 4 years.”
    Quote in the paperSubstantial claim
  • Findingown data

    Compared with non-Hispanic White children, ASD prevalence among children aged 4 years in 2020 was 1.2 times as high among multiracial children.

    “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.”
    • Also stated in: § Demographics · plain
      “Compared with White children, ASD prevalence was higher among Black children at nine sites (overall 1.6 times as high), Hispanic children at seven sites (overall 1.8 times as high), A/PI children at six sites (overall 1.4 times as high), and multiracial children at two sites (overall 1.2 times as high) (Table 3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Compared with non-Hispanic White children, ASD prevalence among children aged 4 years in 2020 was 1.4 times as high among Asian or Pacific Islander children.

    “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.”
    • Also stated in: § Demographics · plain
      “Compared with White children, ASD prevalence was higher among Black children at nine sites (overall 1.6 times as high), Hispanic children at seven sites (overall 1.8 times as high), A/PI children at six sites (overall 1.4 times as high), and multiracial children at two sites (overall 1.2 times as high) (Table 3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Compared with non-Hispanic White children, ASD prevalence among children aged 4 years in 2020 was 1.6 times as high among non-Hispanic Black children.

    “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.”
    • Also stated in: § Demographics · plain
      “Compared with White children, ASD prevalence was higher among Black children at nine sites (overall 1.6 times as high), Hispanic children at seven sites (overall 1.8 times as high), A/PI children at six sites (overall 1.4 times as high), and multiracial children at two sites (overall 1.2 times as high) (Table 3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    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 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.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 34
  • Classified as probably not a substantial claim. 17

  • May combine two claims.

    Findingown data

    In 2020, overall ASD prevalence among children aged 4 years was 32.3 per 1,000 among boys and 10.4 per 1,000 among girls, a male-to-female prevalence ratio of 3.1.

    “For 2020, prevalence was 32.3 per 1,000 boys aged 4 years, which was 3.1 times as high as among girls (10.4) (Table 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Overall, 80.2% of children aged 4 years who met the ADDM Network ASD case definition had a recorded ASD diagnosis, ranging from 54.1% to 98.3%.

    “Overall, 80.2% of children who met the ADDM Network case definition had a recorded ASD diagnosis (range = 54.1%–98.3%) (Figure 1) (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/124396), 38.1% had a recorded ASD eligibility (range = 9.3%–75.1%), and 79.4% had a recorded ASD ICD code (range = 22.0%–92.7%).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Prevalence of suspected ASD increased from 2018 at five sites (Arizona, Arkansas, Maryland, New Jersey, and Utah) and was similar between years at other sites.

    “Prevalence of suspected ASD increased from 2018 at five sites (Arizona, Arkansas, Maryland, New Jersey, and Utah) and was similar between years at other sites (7)”
    • Also stated in: § Conclusion · plain
      “Identification of children with suspected ASD also increased at certain sites compared with 2018 data.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Shaw, 2021, Early identification of autism spectrum disorder among children aged 4 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2018., MMWR Surveill Summ source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    In 2020, among children aged 4 years, ASD prevalence was 28.7 per 1,000 among Hispanic children, 25.3 among Black children, 23.5 among A/PI children, 19.3 among multiracial children, 16.3 among White children, and 11.1 among AI/AN children.

    “Among race and ethnicity groups, Hispanic children had the highest prevalence of ASD at 28.7 among children aged 4 years, followed by Black children (25.3), A/PI children (23.5), multiracial children (19.3), White children (16.3), and AI/AN children (11.1) (Table 3).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Children with ASD and children with suspected ASD were similar by sex, race and ethnicity, intellectual disability, and evaluation by age 36 months.

    “Children with ASD and children with suspected ASD were similar by sex, race and ethnicity, intellectual disability, and evaluation by age 36 months”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Although every site experienced a period of lower evaluation and identification among children aged 4 years, certain sites showed movement toward recovery to prepandemic levels.

    “Although every site experienced a period of lower evaluation and identification among children aged 4 years, certain sites showed movement toward recovery to prepandemic levels.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Compared with White children, ASD prevalence was higher among Black children at nine sites, Hispanic children at seven sites, A/PI children at six sites, and multiracial children at two sites.

    “Compared with White children, ASD prevalence was higher among Black children at nine sites (overall 1.6 times as high), Hispanic children at seven sites (overall 1.8 times as high), A/PI children at six sites (overall 1.4 times as high), and multiracial children at two sites (overall 1.2 times as high) (Table 3).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among children aged 4 years with ASD, 74.4% had more than one component of the ADDM Network case definition in their records, 23.3% had all three, and 9.8% had an ASD ICD code only.

    “A majority of children (74.4%) had more than one component of the case definition in their records and 23.3% had all three; 9.8% had an ASD ICD code only (Figure 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Patterns of evaluations and ASD identification after pandemic onset varied by site, with certain sites (e.g., Georgia, Minnesota, and Utah) having sustained declines in evaluation and identification through the end of the year, but other sites (e.g, Missouri and Tennessee) showing resurgences closer to prepandemic levels.

    “Patterns of evaluations and ASD identification after pandemic onset varied by site, with certain sites (e.g., Georgia, Minnesota, and Utah) having sustained declines in evaluation and identification through the end of the year, but other sites (e.g, Missouri and Tennessee) showing resurgences closer to prepandemic levels”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among children with data on intellectual ability, 48.5% of children with ASD met the surveillance case definition of having co-occurring intellectual disability, with a range from 24.7% in California to 67.3% in Arkansas.

    “Among children with data on intellectual ability, 48.5% of children with ASD met the surveillance case definition of having co-occurring intellectual disability (range = 24.7% in California to 67.3% in Arkansas).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Overall, 58.3% of children aged 4 years with ASD had information on intellectual ability available, ranging from 38.6% in Wisconsin to 89.8% in Arkansas.

    “Overall, 58.3% of children had information on intellectual ability available (range = 38.6% in Wisconsin to 89.8% in Arkansas) (Table 4).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Evaluation by age 36 months was similar by sex and by racial and ethnic groups except for being lower among Black (75.9%) compared with Hispanic (79.8%) children.

    “Evaluation by age 36 months was similar by sex and by racial and ethnic groups except for being lower among Black (75.9%) compared with Hispanic (79.8%) children.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Prevalence among AI/AN children was similar to White children, but Black, Hispanic, A/PI, and multiracial children had an ASD prevalence 2.3, 2.6, 2.1, and 1.7 times as high as AI/AN children, respectively.

    “Prevalence among AI/AN children was similar to White children, but Black, Hispanic, A/PI, and multiracial children had an ASD prevalence 2.3, 2.6, 2.1, and 1.7 times as high as AI/AN children, respectively.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    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.

    “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.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The 8-year-old cohort's evaluation and identification patterns 4 years earlier provide a valid counterfactual for what the 4-year-old cohort would have experienced absent the COVID-19 pandemic.

  • May combine two claims.

    Findingcitation

    In 2020, ASD prevalence among children aged 4 years was 24.3% higher among boys and 34.5% higher among girls than prevalence in 2018.

    “Prevalence in 2020 among children aged 4 years was 24.3% higher among boys and 34.5% higher among girls than prevalence in 2018 (7), but the male-to-female ratios were similar between years.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Shaw, 2021, Early identification of autism spectrum disorder among children aged 4 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2018., MMWR Surveill Summ source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Overall, 38.1% of children aged 4 years who met the ADDM Network ASD case definition had a recorded ASD special education eligibility, ranging from 9.3% to 75.1%.

    “Overall, 80.2% of children who met the ADDM Network case definition had a recorded ASD diagnosis (range = 54.1%–98.3%) (Figure 1) (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/124396), 38.1% had a recorded ASD eligibility (range = 9.3%–75.1%), and 79.4% had a recorded ASD ICD code (range = 22.0%–92.7%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    California continued to report high levels of early ASD identification, with higher prevalence at age 4 years than 8 years in 2020.

    “California continued to report high levels of early ASD identification, with higher prevalence at age 4 years than 8 years in 2020 (11).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Maenner, 2023, Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020., MMWR Surveill Summ source

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    Findings were similar to 2018 by presence of co-occurring intellectual disability and evaluation by age 36 months.

    “Findings were similar to 2018 by presence of co-occurring intellectual disability and evaluation by age 36 months.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    Suspected ASD was highest in the three states (Utah, Arizona, and Arkansas) with the lowest ASD prevalence, and two of the three states with the highest prevalence (California and Tennessee) had the lowest suspected ASD prevalence.

    “Suspected ASD was highest in the three states (Utah, Arizona, and Arkansas) with the lowest ASD prevalence, and two of the three states with the highest prevalence (California and Tennessee) had the lowest suspected ASD prevalence.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Prevalence among girls surpassed 10 per 1,000 children aged 4 years for the first time in ADDM Network surveillance (also observed among children aged 8 years for the first time).

    “Prevalence among girls surpassed 10 per 1,000 children aged 4 years for the first time in ADDM Network surveillance (also observed among children aged 8 years for the first time) (11).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Maenner, 2023, Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020., MMWR Surveill Summ source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Prevalence varied widely across sites in 2020, with prevalence 265% higher in California than in Utah, the site with the lowest prevalence.

    “However, prevalence varied widely across sites in 2020, with prevalence 265% higher in California than in Utah, the site with the lowest prevalence.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The higher prevalence of ASD among Black, Hispanic, and A/PI versus White children aged 4 years first reported in 2018 continued in 2020 and also was seen among children aged 8 years.

    “The higher prevalence of ASD among Black, Hispanic, and A/PI versus White children aged 4 years first reported in 2018 continued in 2020 and also was seen among children aged 8 years (11).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Maenner, 2023, Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020., MMWR Surveill Summ source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    A larger increase in prevalence from 2018 for girls compared with boys was observed; however, the male-to-female ratio was similar across years.

    “A larger increase in prevalence from 2018 for girls compared with boys was observed; however, the male-to-female ratio was similar across years.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Surveillance in 2020 was conducted using the same methods as in 2018.

    “Surveillance was conducted using the same methods as in 2018 (7,10).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [7] Shaw, 2021, Early identification of autism spectrum disorder among children aged 4 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2018., MMWR Surveill Summ source

      Not checked in the free run.

    • cites [10] Maenner, 2021, Comparison of two case definitions for ascertaining prevalence of autism spectrum disorder among 8-Year-old children., Am J Epidemiol source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Prevalence and risk ratios were considered significant when 95% CIs did not include 1.0.

    “Prevalence and risk ratios were considered significant when 95% CIs did not include 1.0.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    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.

    “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.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Higher cumulative incidence of ASD by age 48 months among children aged 4 years compared with children aged 8 years in 2020 reflects improvements in early identification rather than other cohort differences.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    All ADDM Network sites functioned as public health authorities under HIPAA and met applicable local institutional review board, privacy, and confidentiality requirements under 45 CFR 46.

    “All sites functioned as public health authorities under the Health Insurance Portability and Accountability Act of 1996 Privacy Rule and met applicable local institutional review board, privacy, and confidentiality requirements under 45 CFR 46.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Nine sites had data agreements with education sources covering 100% of their study areas, Missouri had agreements covering 50.3%, and Georgia covering 97.6%.

    “Nine sites had data agreements in place with education sources covering 100% of their study areas, Missouri had agreements with education data sources covering 50.3%, and Georgia with education data sources covering 97.6% of its study area.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Prevalence estimates with a relative SE ≥30% were suppressed because of limited statistical precision.

    “Prevalence estimates with a relative SE ≥30% were suppressed because of limited statistical precision.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    A wide range of prevalence of ASD by age 4 years was observed, suggesting differences in early ASD identification practices among communities.

    “A wide range of prevalence of ASD by age 4 years was observed, suggesting differences in early ASD identification practices among communities.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Differences in ASD prevalence by age 4 years across communities reflect differences in early ASD identification practices rather than differences in the true occurrence of ASD.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Increased use of telehealth approaches could reflect the movement toward recovery by enabling remote evaluation and identification of children with ASD.

    “This could reflect increased use of telehealth approaches that enabled remote evaluation and identification of children with ASD (12–16).”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [12] Corona L, Hine J, Ncholson A, TELE-ASD-PEDS: a telemedicine-based ASD evaluation tool for toddlers and young children. Nashville, TN: Vanderbilt University Medical Center; 2020. https://vkc.vumc.org/vkc/triad/tele-asd-peds

      Not checked in the free run.

    • cites [13] Wagner, 2021, Use of the TELE-ASD-PEDS for autism evaluations in response to COVID-19: preliminary outcomes and clinician acceptability., J Autism Dev Disord source

      Not checked in the free run.

    • cites [14] Dow, 2022, The brief observation of symptoms of autism (BOSA): development of a new adapted assessment measure for remote telehealth administration through COVID-19 and beyond., J Autism Dev Disord source

      Not checked in the free run.

    • cites [15] Dow, 2017, Psychometric analysis of the Systematic Observation of Red Flags for autism spectrum disorder in toddlers., Autism source

      Not checked in the free run.

    • cites [16] Dow, 2020, Screening for autism spectrum disorder in a naturalistic home setting using the Systematic Observation of Red Flags (SORF) at 18–24 months., Autism Res source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Surveillance area populations are not necessarily generalizable to the entire state or United States.

    “First, surveillance area populations are not necessarily generalizable to the entire state or United States.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Variability in state-level procedures for early intervention could contribute to differences in prevalence among sites.

    “Variability in state-level procedures for early intervention also could contribute to differences in prevalence among sites.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Arkansas code required agreement by three professionals in specified categories to receive an ASD diagnosis until the code was revised in 2021 to two "qualified professionals," easing the requirements for identification.

    “For example, Arkansas code required agreement by three professionals in specified categories to receive an ASD diagnosis until the code was revised in 2021 to two “qualified professionals” (17), easing the requirements for identification.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Bill A. State of Arkansas 93rd General Assembly HB1545. 2021 Apr 12;5.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The potential complication from changing sites is mitigated by comparing ASD identification between children aged 4 and 8 years in the same study area during the surveillance period.

    “The latter is mitigated by comparing ASD identification between children aged 4 and 8 years in the same study area during the surveillance period.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Sustained decreases could reflect extended remote learning through the end of 2020 in certain sites such as Minnesota, where many children are identified in schools.

    “Sustained decreases also could reflect extended remote learning through the end of 2020 in certain sites such as in Minnesota, where many children are identified in schools (Figure 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Data quality is dependent on data availability and completeness of records at data sources.

    “Second, data quality is dependent on data availability and completeness of records at data sources.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Demographic characteristics reflect what is documented in records; sex and race and ethnicity estimates could be higher or lower if administrative records are different from individual or family preferences.

    “For example, demographic characteristics reflect what is documented in records; sex and race and ethnicity estimates could be higher or lower if administrative records are different from individual or family preferences.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    ASD is beginning to be identified more in lower-SES groups than previously; however, barriers to services still exist for lower-SES families of children with ASD (e.g., transportation, childcare, and job accommodations).

    “ASD is beginning to be identified more in lower-SES groups than previously (7,11); however, barriers to services still exist for lower-SES families of children with ASD (e.g., transportation, childcare, and job accommodations) (18–26).”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [7] Shaw, 2021, Early identification of autism spectrum disorder among children aged 4 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2018., MMWR Surveill Summ source

      Not checked in the free run.

    • cites [11] Maenner, 2023, Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020., MMWR Surveill Summ source

      Not checked in the free run.

    • cites [18] Smith, 2020, Disparities in service use among children with autism: a systematic review., Pediatrics source

      Not checked in the free run.

    • cites [19] Bilaver, 2021, Understanding racial and ethnic disparities in autism-related service use among Medicaid-enrolled children., J Autism Dev Disord source

      Not checked in the free run.

    • cites [20] Magaña, 2012, Racial and ethnic disparities in quality of health care among children with autism and other developmental disabilities., Intellect Dev Disabil source

      Not checked in the free run.

    • cites [21] Magaña, 2013, Access to diagnosis and treatment services among latino children with autism spectrum disorders., Intellect Dev Disabil source

      Not checked in the free run.

    • cites [22] Flores, 2008, Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children., Pediatrics source

      Not checked in the free run.

    • cites [23] Hodgkinson, 2017, Improving mental health access for low-income children and families in the primary care setting., Pediatrics source

      Not checked in the free run.

    • cites [24] Wieckowski, 2022, Addressing current barriers to autism diagnoses through a tiered diagnostic approach involving pediatric primary care providers., Autism Res source

      Not checked in the free run.

    • cites [25] Drahota, 2020, Service deserts and service oases: Utilizing geographic information systems to evaluate service availability for individuals with autism spectrum disorder., Autism source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    These comparisons of characteristics between children with suspected ASD and children with ASD were among children seen for a developmental evaluation; disparities in receiving evaluations could still exist.

    “but these comparisons were among children seen for a developmental evaluation; disparities in receiving evaluations could still exist.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The surveillance case definition of intellectual disability is not the same as a clinical diagnosis; IQ measurements in young children might lack stability and children might not ultimately receive a diagnosis of intellectual disability.

    “Finally, the surveillance case definition of intellectual disability is not the same as a clinical diagnosis; IQ measurements in young children might lack stability and children might not ultimately receive a diagnosis of intellectual disability.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The higher occurrence of ASD among Black, Hispanic, and A/PI groups possibly suggests higher risk for ASD (e.g., perinatal or environmental factors) in populations that were previously masked by socioeconomic disparities in accessing ASD identification and treatment services.

    “The higher occurrence of ASD among these groups possibly suggests higher risk for ASD (e.g., perinatal or environmental factors) in populations that were previously masked by socioeconomic disparities in accessing ASD identification and treatment services.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Higher levels of suspected ASD could reflect community requirements for ASD diagnosis.

    “Higher levels of suspected ASD could reflect community requirements for ASD diagnosis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Sites or study areas could change between study years, which could complicate comparisons over time.

    “Third, sites or study areas could change between study years, which could complicate comparisons over time.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Local factors likely contribute to early identification at the California site, such as hundreds of pediatricians participating in the Get SET Early model and a state-funded regional center that provides evaluations and service coordination for persons with disabilities and their families.

    “Local factors likely contribute to early identification at the California site, such as hundreds of pediatricians participating in the Get SET Early model (27) and a state-funded regional center that provides evaluations and service coordination for persons with disabilities and their families”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Pierce, 2021, Get SET early to identify and treatment refer autism spectrum disorder at 1 year and discover factors that influence early diagnosis., J Pediatr source

      Not checked in the free run.

45 of 45

  • The paper relies on this without support.

    The 8-year-old cohort's evaluation and identification patterns 4 years earlier provide a valid counterfactual for what the 4-year-old cohort would have experienced absent the COVID-19 pandemic.

    “To compare the same age windows by calendar month, the numbers of evaluations and incidence of identification from 2012 (year 0) through 2016 (year 4) for children aged 8 years was subtracted from the same months during 2016 (year 0) through 2020 (year 4) for children aged 4 years.”

  • The paper relies on this without support.

    Differences in ASD prevalence by age 4 years across communities reflect differences in early ASD identification practices rather than differences in the true occurrence of ASD.

    “A wide range of prevalence of ASD by age 4 years was observed, suggesting differences in early ASD identification practices among communities.”

  • The paper relies on this without support.

    Higher cumulative incidence of ASD by age 48 months among children aged 4 years compared with children aged 8 years in 2020 reflects improvements in early identification rather than other cohort differences.

    “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.”

  • The paper relies on this without support.

    Earlier identification of ASD leads to better outcomes.

    “Because earlier identification could lead to better outcomes, follow-up of children suspected but not confirmed of having ASD could help minimize delays in identification and intervention.”
4 of 4

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Authors
Shaw, K. A., Bilder, D. A., McArthur, D., Williams, A. R., Amoakohene, E., Bakian, A. V., Durkin, M. S., Fitzgerald, R. T., Furnier, S. M., Hughes, M. M., Pas, E. T., Salinas, A., Warren, Z., Williams, S., Esler, A., Grzybowski, A., Ladd-Acosta, C. M., Patrick, M., Zahorodny, W., Green, K. K., Hall-Lande, J., Lopez, M., Mancilla, K. C., Nguyen, R. H. N., Pierce, K., Schwenk, Y. D., Shenouda, J., Sidwell, K., Vehorn, A., DiRienzo, M., Gutierrez, J., Hallas, L., Hudson, A., Spivey, M. H., Pettygrove, S., Washington, A., & Maenner, M. J.
Affiliations
  • Centers for Disease Control and Prevention (US)
  • University of Utah (US)
  • University of Wisconsin–Madison (US)
  • Washington University in St. Louis (US)
  • Johns Hopkins University (US)
  • Vanderbilt University Medical Center (US)
  • University of Minnesota (US)
  • University of California San Diego (US)
  • Rutgers New Jersey Medical School (US)
  • University of Arkansas for Medical Sciences (US)
  • University of Arizona (US)
Corresponding author
Shaw, Kelly A.
ORCID
Venue
MMWR. Surveillance Summaries
Publisher
Centers for Disease Control MMWR Office
Published
2023-03-24
Volume
72
Issue
1
Pages
1-15
ISSN
  • 1545-8636 (ISSN-L)
  • 1546-0738
DOI
10.15585/mmwr.ss7201a1
PMC
PMC10042615
OpenAlex
W4360599455
Semantic Scholar
f35fc0eac2ebcd6950ecee824df6cc887c3d5566
Cited by
223
References
23
Citations by year
2026: 17 · 2025: 107 · 2024: 81 · 2023: 18
FWCI
33.32
Type
journal article
Language
en
Open access
Licence
public-domain
Locations
  • MMWR Surveillance Summaries (publishedVersion, public-domain)
  • PubMed Central (publishedVersion, public-domain)
  • PubMed (publishedVersion)
  • UA Campus Repository (The University of Arizona) (submittedVersion, public-domain)
Funders
Eunice Kennedy Shriver National Institute of Child Health and Human Development (P50HD103537)
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
  • Social Sciences › Psychology › Clinical Psychology › Family and Disability Support Research
Keywords
autism spectrum disorder, autism prevalence, early detection, special education eligibility, intellectual disability, sex differences, racial and ethnic disparities, developmental evaluation, cumulative incidence
MeSH terms
Autism Spectrum Disorder, COVID-19, Autistic Disorder, Child, Developmental Disabilities, Female, Humans, Male, Population Surveillance, United States, Utah, Prevalence, Pandemics

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

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