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ELECTRONIC ARTICLE |
From the Department of Biology, Portland State University, Portland, Oregon
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ABSTRACT |
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Key Words: autism • prevalence • education
Abbreviations: USDE, United States Department of Education • IDEA, Individuals With Disabilities Education Act • DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • OAR, Oregon Administrative Rules
The prevalence of autism and whether that prevalence is rising are 2 of the many controversies surrounding this disorder. Much of the controversy is attributable to the difficulty of finding good data. A number of studies have examined the prevalence of autism and related disorders1–6 in a number of different populations and periods. However, all of these studies are constrained by time and funding to examining either a relatively small population or relatively few points in time.
Many autism advocates have used data from the United States Department of Education (USDE) in their presentations to lawmakers7 and the public to show a dramatic and accelerating rise in the prevalence of autism in the United States. Because these data are being used to influence public policy, it is critically important to know if they can be used to reliably measure the prevalence of autism.
This study examined the autism data collected by the USDE by following individual birth-year cohorts through time. It also examined the methods used to collect the USDE autism data and compared those with the methods used by medical practitioners to diagnose autism.
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METHODS |
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USDE data provided the number of children in each single-year age group with the IDEA-qualifying condition of autism. This information was found in the Office of Special Education and Rehabilitation Services’ 14th through 25th Annual Reports to Congress.8 These data are collected by the USDE from the education departments of each state (also from the District of Columbia, Puerto Rico, Guam, and other US possessions and territories), which in turn collect them from the individual school districts. The assessment criteria for autism (and the other IDEA-qualifying categories) are based on legislation passed by the individual state legislatures, as interpreted by the state education departments and local school districts.
Only data from 1993 and later were used, as autism was not reported separately until 1992 and mandatory reporting did not begin until 1993. The study was also restricted to ages 6 through 17 years because children who are younger than 6 and older than 17 are generally not required to attend school and seem to be underrepresented in the USDE data.
Population figures for each single-year age group were obtained from the US Census Bureau and were derived from the 1990 and 2000 decennial censuses. Populations of noncensus years were estimated by the US Census Bureau using their estimation algorithm. Information was extracted from the US Census Bureau’s online database using the DataFerret search and retrieval program (www.dataferrett.census.gov).
Autism prevalence was calculated by dividing the number of children with autism of each age reported to the USDE by the total number of people in the United States of that age in that year. August census estimates were used for noncensus years.
Birth-year cohorts were developed by assigning children of each age to the birth year that corresponded to the middle of that age group (eg, all 6-year-olds in 2000 were assigned to the 1994 birth-year cohort).
2 analysis was used to compare autism prevalence within a birth-year cohort from year to year as well as between birth-year cohorts at a specific age. The expected number of autistic children was calculated by taking the prevalence from the reference group and applying it to the population figure for the group being analyzed.
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RESULTS |
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DISCUSSION |
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Autism, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV), is a developmental disorder that is usually first observed between birth and 3 years of age. Although it is often diagnosed later, the impairments must be present by age 3 years to make the diagnosis of autism.9 Four recent studies examined age of first diagnosis of autism and suggested that the majority of diagnoses are made before the age of 8 years.
A study of records from British general practitioners found that the mean age at first diagnosis was 6.25 years (SD: 4.52 years).10 A study of 2 cohorts (born 1974–1983 and 1984–1993) in Iceland showed an even younger age at first diagnosis: 3.6 years and 4.0 years, respectively (ranges: 1.7–17 and 2.2–13.8 years, respectively).1 A study of Medicaid-eligible children in Philadelphia, Pennsylvania, had a mean age at first diagnosis of 7.4 years (SD: 3.1 years).11
One study of a single health district in Northern England looked specifically at the difference in timing of medical diagnosis and educational assessment (statement of special educational needs). They found that, for children in mainstream schools, the mean age at diagnosis was 6.5 years (range: 2–12 years) and the mean age of receiving a statement of special educational needs was 5.6 years, indicating that the educational assessment of autism generally preceded the medical diagnosis.12
The interval between ages 11 and 12 years is the time when most children make the transition from elementary school to middle school. Although it might be expected that moving from the structured academic and social environment of elementary school to the more self-directed environment of middle school would "unmask" milder cases of autism, the USDE data show just the opposite. Most (5 of 6) of the cohorts that have complete data for the period surrounding this transition show a greater rise in autism prevalence for the 2 years before middle school than in the 2 years after the transition to middle school.
The USDE data suggest that the prevalence of autism is rising, but is this attributable to an actual increase in prevalence or to a broader definition of autism and greater public awareness? A number of studies have suggested that the diagnosis of autism, even by medical practitioners, has experienced significant drift over time.1,4,5 A review by Wing and Potter13 provides an excellent overview of this problem. A recent study of autism incidence between 1976 and 1997 concluded that the timing of the increase in autism diagnoses suggests that it was attributable to increased awareness and changes in diagnostic criteria.14
Despite the specific diagnostic criteria provided by the DSM-IV, the diagnosis of autism is completely subjective. There are no objective findings, radiologic studies, or laboratory tests that are diagnostic for autism. Even the presence of disorders such as fragile X15,16 or tuberous sclerosis,17,18 which are often associated with autism, are not diagnostic of autism, because only a fraction of patients with these conditions have autism.
Finally, at least 2 studies have suggested that autistic traits are not a discrete feature seen only in the presence of autism but rather are a continuum. As such, a certain degree of "autistic" behaviors can be expected in many "typical" individuals.19,20 This further complicates the diagnosis of autism, because there is no distinct "cutoff" point between typical and autistic. There are indications that the increasing awareness of autism in the medical and educational communities may have led to a gradual shift in diagnosis to include less disabled individuals who would not previously have been described as autistic13 or would have received a different diagnosis.5
Although the diagnosis of autism seems to have changed with time, the guidelines for educational assessment of autism also vary from state to state. With only 10 qualifying disabilities under IDEA,21 the assessment criteria used by the states are understandably broad. As, perhaps, an extreme example of this, compare a section of the diagnostic criteria for autism from the DSM-IV with the corresponding section of the assessment criteria used in the state of Oregon (from the Oregon Administrative Rules [OAR]):
DSM-IV:
"(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (eg, by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity"10
OAR:
"(ii) Impairments in social interaction"22
The criteria found in the OAR are obviously much broader and more general than those in the DSM-IV. The choice of Oregon for this comparison was not random: Oregon has consistently had the highest prevalence of autism in the USDE data of any state (2 to 3 times the national prevalence) since autism was first reported as a separate disability.
As has been shown, the USDE data on autism are at odds with studies of autism prevalence, largely because the criteria used by the school districts (the source of the USDE data) to categorize children as autistic are neither rigorous nor consistent. They are inconsistent over time, as are the medical criteria, and are inconsistent from region to region. The USDE data are not reliable for tracking the prevalence of autism, and they in fact never were meant to fill this need.
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FOOTNOTES |
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Reprint requests to (J.R.L.) Department of Biology, Portland State University, PO Box 751, Portland, OR 97207-0751. E-mail: laidlerj{at}pdx.edu
No conflict of interest declared.
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This article has been cited by other articles:
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  S. A. Bryson, S. K. Corrigan, T. P. Mcdonald, and C. Holmes Characteristics of children with autism spectrum disorders who received services through community mental health centers Autism, January 1, 2008; 12(1): 65 - 82. [Abstract] [PDF]
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