1. Risk of Autism and Birth Certificate Data: A Utah Population Based Study Robert Satterfield 1, Epidemiologist Judith P. Zimmerman 2, Ph.D. Shaheen Hossain 1, Ph.D. Lynne M. MacLeod 1, M.Stat. Judith Miller 2, Ph.D. William McMahon 2, MD. 1 Utah Department of Health 2 Utah Registry of Autism and Developmental Disabilities

2. Background  Autism and Developmental Disabilities Monitoring Network (ADDM)  Utah Registry of Autism and Developmental Disabilities (URADD)  Special project to study how many individuals with ASDs and developmental disabilities there are in Utah  Public awareness campaign  Self-reporting registry

3. Background: Autism and Developmental Disabilities Monitoring Network (ADDM)

4. Background: Impact of ASD  Frequency: Recent increases  Severity: Lifelong impairment  Identified in all races, ethnic groups, social classes  Costs: Significant – $90 billion in 2000*  Preventability: Unknown cause but genetics implicated; other exposures have been blamed Environmental contaminants Vaccines *Jarbrink K, Knapp M, 2001 London School of Economics, 2001

5. Other Autism Studies  Male / female ratio varies from 1.33 to 16.0 with a median ratio of 2.55 (mean 3.7)  Cognitive impairment in classic autism – ~80%  Less in PDD-NOS  Not associated with Aspergers  Seizures: range 4.8-26.4% with a median rate of 16.7%  2006 Israeli study suggests offspring of men 40 years or older were 5.75 times more likely to have ASD Fombonne, 1999 Reichenberg, et. al. 2006

6. Changing Prevalence  Numerous studies with different methodologies  Pre-1985: 2 cases per 10,000 for classic autism; 4-5 cases per 10,000 for all ASDs  Post-1985: 20-40 cases per 10,000 for classic autism; 34-67 cases per 10,000 for all ASDs  2005: NHIS Autism Estimates 5.7 per 1000

7. Chronological Autism Studies from 1966 - 2003 Adapted from Fombonne, 2001

8. Utah School Autism Exceptionality Prevalence Data: 1996-2005

9. Purpose  To determine the prevalence of ASDs and also to identify potential risk factors related to ASDs

10. Study Question  Is there an association between certain maternal pregnancy / delivery complications and the risk of autism?

11. Utah Demographics  Population: 2,358,330  Growth Rate: 7 th (1.6% from 2003-04)  Fertility Rate: 1 st (2.56 births)  Household Size: 1 st (3.13 persons)  Age of Population: 1 st (youngest, 27.5 years)  *Pupil/Teacher Ratio: 22.4 (U.S. average 15.9) Governor’s Office of Planning and Budget, *2005 National Center for Education Statistics, 2006

12. Study Demographics  Utah’s 2002 study year population Born in 1994 Lived in Davis, Salt Lake, and/or Utah Counties in 2002 Received special education and/or diagnoses associated with ASD and/or cognitive impairment before 12/31/02

13. Demographics NumberPercentage State of Utah38,751 Males 19,991 Females 18,760 100.0% 51.6% 48.4% Study Area26,108 Males 13,464 Females 12,644 67.6% 51.6% 48.4% Salt Lake14,85638.3% Davis4,42311.4% Utah6,82917.6%

14. Methodology  Utah birth certificate and URADD data were used for this study  Data were linked using SAS version 9, with a deterministic followed by probabilistic approach  Performed multivariate logistic analysis

15. Results CharacteristicsAutism Cases Birth Cohort (n=114) (n=26,830) Male 82.5%** 51.7% Female17.5%** 48.3% Avg. Birth Weight (grams)3192* 3338 Prenatal Care in 1st trimester92.0% 86.3% Avg. Prenatal Care Visits11.4 10.9 * Significant at <.05 ** Significant at <.001

16. Results Risk FactorsAdjusted OR* Confidence Intervals Breech2.39 (1.24 - 4.63) Primary C-Section1.96 (1.15 - 3.34) Assisted Ventilation <300.36 (0.05 - 2.60) Assisted Ventilation >303.67 (1.42 - 9.48) * Model controlled for multiple gestations, tobacco use during pregnancy, gestational age, maternal age, maternal education, maternal marital status, and parity

17. Method of Delivery MODAutism Cases % Birth Cohort % Vaginal67.5**80.8 Primary C-Section20.2**9.2 Repeat C-Section5.3*6.9 VBAC7.0*3.0 * Significant at <.05 ** Significant at <.001

18. Maternal Characteristics CharacteristicsAutism Cases Birth Cohort Maternal Age (years)27.2 26.6 Maternal Education (years)13.813.3 Hispanic Origin4.4%7.0%

19. Paternal Characteristics CharacteristicsAutism Cases Birth Cohort Paternal Age (years)29.329.2 Paternal Education (years)14.214.0 Hispanic Origin4.5%6.5%

20. Conclusions  The study found a nearly 5 to 1 autism occurrence in males vs. females (82.5% p <.0001)  Autism cases had significantly higher histories of breech presentation (AOR=2.39 CI 1.24 – 4.63)  Autism cases had significantly higher occurrences of Primary C-section (AOR=1.96 CI 1.15 – 3.34)

21. Conclusions  Significant differences were found in average birth weight for children with autism compared to the general birth cohort (3192 grams verses 3338 grams, p <.005)  Autism cases had significantly higher occurrences of Assisted ventilation > 30 minutes (AOR=3.67 CI 1.42 – 9.48)  Analyses showed no statistically significant association between risk of autism and parity, number of PNC visit and entry into prenatal care

22. Implications  Invaluable use of multi-sourced linked data  Early identification of risk factors related to autism may facilitate early intervention and treatment and can significantly improve a child’s development  The recent rise in medial attention on causes of autism, clearly deserve more resources and investigation into these areas  Future direction, Merging with: Hospital Discharge, prescription medication database, Medicaid data

23. Acknowledgement  Centers for Disease Control and Prevention (funded by Cooperative Agreement UR3/CCU822365)  Utah State Office of Education  Alpine, Davis, Jordan, Granite, Murray, Nebo, Provo, & Salt Lake School Districts  Utah School for Deaf and Blind  University of Utah Hospital and Clinics  Intermountain Health Care  Valley Mental Health & Carmen B. Pingree School of Autism  Wasatch Mental Health & GIANT Steps Autism Program  Davis Mental Health & Northern Utah Autism Program  The Children’s Center  Utah Attorney General’s Office  Local Health Departments  Utah Department of Health, Office of Vital Records and Statistics

24. Questions? Thank You! Contact Information: Robert Satterfield, Epidemiologist II UDOH / CFHS / MCH / DRP (801) 538-6967 rsatterfield@utah.gov