1. 2008 A UTISM S PECTRUM D ISORDERS P REVALENCE R ESULTS 2008 A UTISM S PECTRUM D ISORDERS P REVALENCE R ESULTS

2. Overview Describe what autism is Describe the Autism and Developmental Disabilities Monitoring (ADDM) Network and its methodology Present the 2008 results Present surveillance trends for Arapahoe County

3. What is Autism? A group of developmental disabilities that cause significant social, communication and behavioral challenges over a lifetime. Can range from mild to severe.

4. * CDC Slide

5. ADDM N ETWORK M ETHODS Active case-finding with broad retrospective records-based screening for ASD classifications or behaviors. Focus on children at age 8 to identify peak prevalence. Multiple health and education sources of information. Detailed behavioral, developmental, and testing information collected. Ongoing quality control within and across sites. Independent review and clinician confirmation of ASD case status based on the DSM-IV criteria. Standard for setting ASD prevalence estimates in the U.S. * CDC Slide

6. C OLORADO M ONITORING P ROJECT Goal: Determine the prevalence of autism spectrum disorders (ASD) among children who were 8 years of age in 2008. Denver Metropolitan area: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, and Jefferson counties “Complete participation”: Areas with both health sources and school district participation –2002: Arapahoe and Boulder counties –2006 and 2008: Arapahoe county “Incomplete participation”: - 2008: Adams, Boulder, Broomfield, Denver, Douglas, and Jefferson counties

7. Permission to Access Records Health care facilities: – ASD is a reportable public health condition Children < 10 years of age with confirmed or suspected ASD identified by health facilities in the Denver Metropolitan area are reportable to the Colorado Department of Public Health and Environment. Schools: –Individual agreements were developed with each participating school district and/or IRB approvals.

8. Lisa Miller, MD, MSPH Andria Ratchford, MSPH (Project Coordinator) Jean Menconi, RN (Abstractor) Vicki Bondurant (Abstractor) Stephanie Comienski (Abstractor) Beverly Meek (Abstractor) Kevin Hake (Data Manager) 2006 AND 2008 C OLORADO ADDM Corry Robinson, PhD, RN Judy Reaven, PhD (Expert Reviewer) Terry Hall, MA, CCC-SLP (Expert Reviewer) Andrea Hoog (Expert reviewer) Gina Quintana Yolanda Castillo, MBA (Project Coordinator) Gabriela Perez (Abstractor)

9. R ESULTS 2008 8 year olds

10. 2008 C OLORADO P OPULATION C HARACTERISTICS Arapahoe county 6-county Denver area Population CharacteristicsN%N% Total 8 year-old Population in 20087,72529,336 White, Non-Hispanic3,99051.716,92357.7 Black, Non-Hispanic1,05113.61,3904.7 American Indian/Alaskan Native, Non-Hispanic 640.81840.6 Asian, Non-Hispanic3875.01,1794.0 Hispanic (regardless of race)2,23328.99,66032.9

11. Source Characteristics Arapahoe County source types –School: 19% –Health: 22% –Both: 59% Denver metro area source types –Health: 100%

12. ADDM N ETWORK 2008 ASD estimated prevalence per 1,000 persons among 8-year-old children

13. Surveillance Year Birth Year# sites 8-year-old Population 8-year-olds with an ASD Avg Prev/1000 Range 200019926187,7611,252 6.7 4.5-9.9 2002199414407,5782,685 6.6 3.3-10.6 200419968172,3351,376 8.0 4.6-9.8 2006199811308,0382,759 9.0 4.2-12.1 2008200014337,0933,820 11.3 4.8 – 21.2 ADDM N ETWORK O VERALL ASD Estimated Prevalence, 2000-2008 * modified CDC Slide

14. ADDM N ETWORK 2008 Estimated Prevalence by Sex ADDM networkArapahoe County Males18.4 per 1,000(1 in 54)20.1 per 1,000(1 in 50) Females4.0 per 1,000(1 in 250)2.9 per 1,000(1 in 345) Male to female ratio almost 5 boys to every 1 girl7 boys to every 1 girl

15. ADDM NETWORK 2008 Estimated Prevalence per 1,000 by Race /Ethnicity ADDM NetworkArapahoe County Average rateRangeRate95% CI White, non-Hispanic12.04.6 - 40.014.811.5 - 19.1 Black, non-Hispanic10.23.0 - 25.910.55.8 - 18.9 Hispanic 7.91.4 - 20.0 6.74.1 - 11.1

16. Associated Features of ASD Cases, Arapahoe County, 2008 A SSOCIATED FEATURE NPercent Abnormality in eating/drinking 5358.2 Abnormality in sleeping3538.5 Abnormality in mood/affect 7784.6 Abnormality in cognitive skills 3740.7 Aggression 5054.9 Argumentative, defiant, oppositional 7582.4 Delayed motor functioning 7481.3 Hyperactivity, attention problems 8795.6 Lack of fear or excessive fear 4650.5 Odd response to sensory stimuli 7380.2 Self-injurious behavior 3033.0 Staring spells/seizure-like activity 2224.2 Temper tantrums 4650.5

17. MMWR / March 30, 2012 / Vol. 61 / No. 3 Estimated prevalence of ASDs by IQ, ADDM Network, 2008

18. Proportion estimated incidence by IQ scores, Arapahoe County, 2008 36% of all cases in Arapahoe County had an unknown IQ score

19. 2002, 2006 and 2008 C OMPARISON

20. Change in Estimated ASD Prevalence by Race/Ethnicity, Arapahoe County, 2008 Prevalence per 1,000 persons

21. Change in ASD Prevalence from 2002 to 2006 and 2006 to 2008 by Cognitive Functioning Level, ADDM Network Cognitive impairment (IQ ≤ 70) Borderline (IQ = 71-85) Average to above average (IQ > 85) Overall percent change*, 2002 to 2006 359072 Overall percent change**, 2006 to 2008 122313 * From MMWR December 18, 2009 / 58(SS10);1-20 ** From MMWR / March 30, 2012 / Vol. 61 / No. 3

22. A RAPAHOE C OUNTY : E ARLIEST D OCUMENTED D IAGNOSIS Earliest ASD Diagnosis in an Evaluation200220062008 Median Age 62 months 60 months 54 months

23. ADDM Network Summary of Findings, 2008 Estimated prevalence of ASDs continues to rise in most ADDM Network communities, including Arapahoe County Average prevalence of ASDs > 1% of 8-year-olds Average = 1 in 88 eight-year-old (1 in 85 in Arapahoe County) 23% increase, 2006-2008 78% increase, 2002-2008 Estimated prevalence of ASDs varies widely –Across sites –By sex –By race/ethnicity *Modified CDC Slide

24. G ENERAL I SSUES : W HY IS THE IDENTIFIED PREVALENCE OF ASD RISING ? Changes in diagnostic criteria over time Increased awareness in the community Changes in availability of services Parents as advocates Development of specialty services Training of professionals Recognition that ASDs can occur with severe ID, higher intellectual functioning, and other medical and psychiatric disorders True increase in symptoms in the population Increased risk due to environmental and/or genetic factors *CDC Slide

25. Extra Slides

26. ASD characteristics Measured intelligence Severe-------------------------------------Gifted Social interaction Aloof----------------Passive-------------Active but odd Communication Nonverbal------------------------------------------Verbal Behaviors Intense-----------------------------------------------Mild Sensory Hyposensitve---------------------------Hypersensitive Motor Uncoordinated-----------------------------Coordinated Slide courtesy of Catherine Rice, PhD

27. Percent of cases in special education and with an ASD classification, ADDM Network, 2008

28. Earliest Known ASD Diagnosis Median Age and Proportion by Diagnostic Subtype ADDM Network and Arapahoe County, 2008 Subtype of Earliest Diagnosis: Autistic Disorder ASD/PDD Asperger Disorder Distribution of subtypes, ADDM Network: 44%47%9% Median age of earliest diagnosis, ADDM Network: 48 months53 months75 months Distribution of subtypes, Arapahoe County 46%40%14% Median age of earliest diagnosis, Arapahoe County 52 months54 months79 months

29. Percent of Children with ASD by Primary Education Eligibility Category, Arapahoe County 2008 Primary Exceptionality Percent Autism 39.0 Emotional disturbance 2.6 Speech/Language Disability 19.5 Other Physical Disability 27.3 Multiple Disabilities with Cognitive Impairment 7.8 Intellectual disability 3.9 84.6% of all children were receiving Special Education services

30. Change in Estimated ASD Prevalence by Sex, Arapahoe County, 2008 Prevalence per 1,000 persons Study year

31. ADDM Network Implications of Findings ASDs continue to be an important public health concern –~1 million children with ASDs in the United States Better identification among certain subgroups More children than ever are being recognized as having an ASD –Many may not be recognized as early as they can be * Modified CDC Slide

32. Estimated ASD prevalence among 8-year-olds, by access to education records and population size covered, ADDM Network, 2008 MMWR / March 30, 2012 / Vol. 61 / No. 3

33. Proportion of children identified with ASDs by previous ASD classification as of age 8 years, by state and year, ADDM Network, 2008 MMWR / March 30, 2012 / Vol. 61 / No. 3

34. Change in Estimated ASD Prevalence per 1,000 Children by Cognitive Functioning Level – ADDM Network, 7 S ITES, 2002 to 2008 *CDC Slide

35. Previous diagnosis, ADDM Network, 2008 79% of cases had a previously documented ASD classification Range: 67% (Arapahoe County)–87% (Pennsylvania and Wisconsin). In Arapahoe County, –67% had an previous ASD diagnosis –11% had a suspicion of ASD noted –22% had no mention of ASD noted

36. Number of Records Screened Denver Metro Area Records Reviewed ~ 3,019 –Number of records abstracted = 546 Arapahoe County Records Reviewed ~1,282 –Number of records abstracted = 177 –5 of 5 districts participated