Psychiatric and Medical Conditions in

Transition-Aged Individuals With ASD

Meghan N. Davignon, MD,​a,​b Yinge Qian, PhD,​c Maria Massolo, PhD,​c Lisa A. Croen, PhDc

BACKGROUND AND OBJECTIVES: Children with autism spectrum disorder (ASD) have a variety of abstract
medical and psychiatric conditions and an increased use of health care services. There
is limited information about the prevalence of psychiatric and medical conditions in
adolescents and young adults with ASD. Our objective was to describe the frequency of
medical and psychiatric conditions in a large population of diverse, insured transition-aged
individuals with ASD.
METHODS: Participants included Kaiser Permanente Northern California members who were
enrolled from 2013 to 2015 and who were 14 to 25 years old. Individuals with ASD
(n = 4123) were compared with peers with attention-deficit/hyperactivity disorder
(n = 20 615), diabetes mellitus (n = 2156), and typical controls with neither condition
(n = 20 615).
RESULTS: Over one-third (34%) of individuals with ASD had a co-occurring psychiatric
condition; the most commonly reported medical conditions included infections (42%),
obesity (25%), neurologic conditions (18%), allergy and/or immunologic conditions (16%),
musculoskeletal conditions (15%), and gastrointestinal (11%) conditions. After controlling
for sex, age, race, and duration of Kaiser Permanente Northern California membership,
most psychiatric conditions were significantly more common in the ASD group than in each
comparison group, and most medical conditions were significantly more common in the ASD
group than in the attention-deficit/hyperactivity disorder and typical control groups but
were similar to or significantly less common than the diabetes mellitus group.
CONCLUSIONS: Although more research is needed to identify factors contributing to this excess
burden of disease, there is a pressing need for all clinicians to approach ASD as a chronic
health condition requiring regular follow-up and routine screening and treatment of medical
and psychiatric issues.

aDepartment of Pediatrics, The Permanente Medical Group, Inc, Oakland, California; bKaiser Permanente Roseville Medical Center, Roseville, California; and cDivision of Research, Kaiser

Permanente Northern California, Oakland, California

Dr Davignon helped design the study and collaborated in drafting the initial manuscript; Dr Croen conceptualized and designed the study and collaborated in
drafting the initial manuscript; Dr Massolo collaborated in the conceptualization and design of the study and reviewed and revised the manuscript; Dr Qian
conducted the initial and subsequent analyses, collaborated in creating tables and figures, and reviewed and revised the manuscript; and all authors approved the
final manuscript as submitted.
DOI: https://​doi.​org/​10.​1542/​peds.​2016-​4300K
Accepted for publication Sep 26, 2017
Address correspondence to Meghan N. Davignon, MD, Kaiser Roseville Medical Center, 1600 Eureka Rd, Building C, Roseville, CA 95661. E-mail: meghan.davignon@
kp.org

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Autism spectrum disorders (ASDs) Health Plan provides insurance was guided by phenotype-wide
are a heterogeneous group of coverage for inpatient, outpatient, association study methodology‍9
neurodevelopmental disorders and mental health care provided at and previously validated algorithms
characterized by impairments in KPNC hospitals, clinics, and other (Supplemental Table 3).
communication, social interaction, and approved facilities. All patient Intellectual disability (ID),
repetitive behavior.‍1 The dramatic encounters are recorded in electronic developmental disability, and genetic
rise in ASD prevalence in children‍2 medical records (EMRs). disorders were defined by diagnoses
over recent decades is resulting in All individuals 14 to 25 years of age documented in the EMR anytime
increasing numbers of individuals as of January 1, 2014, who were through 2015. Psychiatric and
with ASD transitioning from pediatric members of KPNC for at least medical conditions were defined by
to adult medical services. 9 months in each calendar year diagnoses documented in the EMR
Children with ASD have many from 2013 to 2015 were eligible for from 2014 to 2015. Overweight and
comorbidities including seizure, inclusion (N = 385 051). Individuals obesity were defined by the average
sleep disorders, gastrointestinal with an ASD diagnosis recorded in the BMI recorded in the 2-year study
(GI) disorders, behavioral problems, EMR before 2014 were considered period (Supplemental Table 3).
anxiety, and depression.‍3 Authors of cases (n = 4123; see Supplemental
Table 3 for International Classification Statistical Analysis
recent studies have indicated that
adults with ASD also have elevated of Diseases, Ninth Revision [ICD-9] The prevalence of each condition was
rates of psychiatric and major codes). Approximately 34% were compared between ASD cases and
medical conditions.‍4 Although the diagnosed by specialists at a KPNC each comparison group by using χ2
use and cost of health care services ASD evaluation center after a tests. A separate multivariate logistic
have been shown to be significantly comprehensive clinical assessment, regression model was run for each
elevated in adolescents with ASD,​‍5 including the Autism Diagnostic condition to compare odds between
robust estimates of the prevalence of Observation Schedule,​‍7 and 66% had cases and controls after controlling
medical and psychiatric conditions a diagnosis recorded by nonspecialists for sex, age, race, and total months
among adolescents and young adults on 2 separate occasions. of KPNC membership from 2013
with ASD are lacking. Three comparison populations were to 2015. To address possible
In this study, we examined chosen from among all individuals ascertainment bias, additional
the occurrence of medical and without any ASD diagnoses recorded models were run also adjusting for
psychiatric conditions diagnosed in in the EMR by the end of 2015. A the number of outpatient visits. The
a large insured transition-aged ASD neurodevelopmental group was threshold for statistical significance
population and compared rates to randomly sampled from individuals was set at P < .05. All study
age-matched individuals with other with attention-deficit/hyperactivity procedures were approved by the
neurodevelopmental disorders, disorder (ADHD; n = 20 615; KPNC Institutional Review Board.
chronic medical conditions, and the Supplemental Table 3). A medically
general population. defined group was composed of all
RESULTS
individuals with diabetes mellitus
(DM; n = 2156) in the KPNC diabetes The demographic characteristics of
METHODS registry.‍8 A typical control (TC) the study population are shown in
group (n = 20 516) was randomly ‍Table 1. Among the 4123 individuals
Study Population sampled from individuals with no with ASD, the mean age was 18.4
ADHD and DM diagnoses by the end years (SD 3.2 years), and the male
The study population was drawn
of 2015. The ADHD and TC groups to female ratio was 4:1. Individuals
from the membership of Kaiser
were sampled at a 5:1 ratio to cases with ASD were more likely than
Permanente Northern California
and matched on sex and age group TC and DM groups to be white,
(KPNC), a large integrated health
(14–17, 18–21, 22–25). non-Hispanic, and more likely than
care delivery system providing
all 3 comparison groups to have
care to over 3.8 million residents
Co-occurring Conditions Medicaid.
in the greater San Francisco and
Sacramento areas. KPNC members All diagnoses were identified from Thirteen percent of transition-aged
have similar socio-demographic the KPNC EMR. Over 1000 ICD-9 youth with ASD had a diagnosis of ID
characteristics to other community codes were grouped into 175 (15% mild, 9% moderate, 5% severe,
members locally and statewide, conditions (eg, epilepsy) within 2% profound, 69% unspecified).
except at the extreme ends of the 20 categories (eg, neurology). The The prevalence of ID increased
income distribution.‍6 The Kaiser definition of specific conditions with age (11% in 14–17-year-olds,

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TABLE 1 Demographic Characteristics of Transition-Aged Individuals 14–25 Years of Age From KPNC, 2014–2015
Characteristics ASD TC ADHD DM
n = 4123 n = 20 615 n = 20 615 n = 2156
n (%) n (%) P n (%) P n (%) P
Age group, y <.0001
  14–17 1882 (45.65) 9410 (45.65) 9410 (45.65) 638 (29.59)
  18–21 1402 (34.00) 7010 (34.00) 7010 (34.00) 750 (34.79)
  22–25 839 (20.35) 4195 (20.35) 4195 (20.35) 768 (35.62)
Sex <.0001
  Female 797 (19.33) 3985 (19.33) 3985 (19.33) 1118 (51.86)
  Male 3326 (80.67) 16 630 (80.67) 16 630 (80.67) 1038 (48.14)
Race <.0001 <.0001 <.0001
  White, non-Hispanic 2208 (53.55) 7502 (36.39) 11 903 (57.74) 981 (45.50)
  White, Hispanic 286 (6.94) 1055 (5.12) 1277 (6.19) 168 (7.79)
  African American 339 (8.22) 1933 (9.38) 2330 (11.30) 260 (12.06)
  Asian 649 (15.74) 3910 (18.97) 1406 (6.82) 297 (13.78)
  Other 641 (15.55) 6215 (30.15) 3699 (17.94) 450 (20.87)
Insurance <.0001 <.0001 <.0001
  KP 3183 (77.20) 18 495 (89.72) 17 935 (87.00) 1826 (84.69)
  Medicaid 821 (19.91) 1590 (7.71) 2068 (10.03) 279 (12.94)
  Self-pay 119 (2.89) 530 (2.57) 612 (2.97) 51 (2.37)
Mean age (SD), y 18.39 (3.22) 18.44 (3.18) .3667 18.40 (3.15) .7947 19.77 (3.35) <.0001
Mean length of 35.82 (0.63) 35.77 (0.73) <.0001 35.78 (0.73) .0005 35.70 (0.82) <.0001
membership in
2013–2015 (SD), mo
KP, Kaiser Permanente.

12% in 18–21-year-olds, 19% in dependence was significantly less in children with ASD had a relatively
22–25-year-olds) and was higher in common in the ASD group than in all lower prevalence, including sleep
females (20%) than males (11%). 3 comparison groups (‍Table 2). Less disorders (7%), endocrine conditions
In addition to their ASD diagnosis, common disorders associated with (3%), and metabolic (3%) disorders
41% had received a developmental high morbidity or mortality were (‍Table 2, ‍Fig 1).
disorder (DD) diagnosis at some also significantly more prevalent in
Compared with the TC group,
point in the past (20.7% global individuals with ASD compared with
individuals with ASD were at
delay, 23% language disorder, 11% those in the control group, including
significantly increased risk for
learning disorder, 4% motor delay). schizophrenic disorders (ASD: 1%;
most medical conditions (‍Table 2,
However, during the 2-year study versus TC: 0.3%, adjusted odds ratio
‍Fig 1). The highest risks were seen
period, only 4.3% had 1 or more of [aOR] = 3.6, 95% confidence interval
for epilepsy (aOR = 11.9), genetic
these diagnoses documented in their (CI): 2.4–5.3; versus ADHD: 0.6%,
disorders (aOR = 7.7), dyslipidemia
medical record (‍Table 2). aOR = 1.9, 95% CI: 1.3–2.6; versus DM:
(aOR = 4.9), constipation (aOR = 3.5),
0.7%, aOR = 2.0, 95% CI 1.1–3.8) and
endocrine conditions (aOR = 3.2),
Psychiatric Conditions suicide and self-inflicted injury (ASD:
and sleep disorders (aOR = 3.1).
0.7%; versus TC: 0.3%, aOR = 3.6, 95%
Over one-third (34%) of individuals Antipsychotic medications, a
CI: 2.4–5.3; no significant difference
with ASD had a co-occurring known risk factor for obesity and
versus ADHD [0.9%] or DM [0.9%]).
psychiatric condition; the most dyslipidemia,​‍10 were used by 19%
common were ADHD (15%), anxiety of individuals with ASD. However,
(14%), depression (10%), and bipolar Medical Conditions among individuals who did not
disorder (6%) (‍Table 2). In adjusted take antipsychotic medications,
analyses, most psychiatric conditions The most common medical obesity and dyslipidemia remained
were significantly more common conditions in transition-aged significantly more common in the
in the ASD group than in each individuals with ASD included ASD group versus the TC group
comparison group, with 2 exceptions. infections (42%), obesity (25%), (obesity: 23% vs 15%, P < .0001;
Depression was significantly more neurologic conditions (18%), allergy dyslipidemia: 2.5% vs 0.7%, P <
common in the ASD group versus and/or immunology conditions .0001). Functional GI disorders,
the TC group but significantly less (16%), musculoskeletal conditions genitourinary and renal conditions,
common in the ASD group versus the (15%), and GI conditions (11%). infectious diseases as a group,
ADHD group, and drug abuse and/or Other conditions previously reported and hereditary and degenerative

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 TABLE 2 Comparison of Psychiatric and Medical Conditions in Transition-Aged Individuals 14–25 Years of Age With ASD, ADHD, DM, and TCs From KPNC, 2014–2015

S338
Condition n (%) aOR (95% CI)a
ASD, TC, ADHD, DM, ASD Versus TC ASD Versus ADHD ASD Versus DM
n = 4123 n = 20 615 n = 20 615 n = 2156
Developmental disabilityb 177 (4.3) 23 (0.1) 228 (1.1) 22 (1.0) 42.81 3.97 (3.24–4.86)c 5.56 (3.48–8.88)c
(27.56–66.50)c
  Global developmental delay 77 (1.9) 11 (0.05) 64 (0.3) 9 (0.4) 38.37 5.96 (4.25–8.36)c 7.80
(20.24–72.71)c (3.78–16.12)c
  Language disorder 73 (1.8) 2 (0.01) 25 (0.1) 1 (0.05) 194.76 14.51 37.20
(47.62–796.57)c (9.15–23.02)c (5.10–271.46)c
  Learning disorder 27 (0.6) 9 (0.04) 130 (0.6) 8 (0.4) 16.16 1.05 (0.69–1.60) 1.82 (0.78–4.27)
(7.45–35.03)c
Psychiatric conditions (includes ADHD)b 1419 (34.4) 1905 (9.2) 8883 (43.1) 534 (24.8) 4.97 (4.58–5.39)c 0.70 (0.65–0.75)c 1.84 (1.62–2.09)c
Psychiatric conditions (without ADHDd) 1168 (28.3) 1905 (9.2) 5424 (26.3) 503 (23.3) 3.73 (3.43–4.06)c 1.14 (1.06–1.23)c 1.62 (1.42–1.85)c
  Anxiety 595 (14.4) 776 (3.8) 2352 (11.4) 204 (9.5) 4.01 (3.57–4.50)c 1.33 (1.21–1.47)c 1.91 (1.59–2.30)c
  ADHDd 602 (14.6) 0 (0.0) 6443 (31.2) 77 (3.6) —d —d 3.97 (3.08–5.11)c
  Bipolar disorder 264 (6.4) 133 (0.6) 963 (4.7) 61 (2.8) 9.58 (7.72–11.88)c 1.48 (1.28–1.70)c 2.80 (2.07–3.79)c
  Depression 410 (9.9) 821 (4.0) 2392 (11.6) 282 (13.1) 2.51 (2.21–2.85)c 0.85 (0.76–0.95)c 0.94 (0.79–1.12)
  Disruptive, impulse, and conduct disorders 143 (3.5) 60 (0.3) 560 (2.7) 23 (1.1) 11.93 1.35 (1.12–1.63)c 3.91 (2.45–6.24)c
(8.75–16.26)c
  Drug abuse and/or dependence 63 (1.5) 458 (2.2) 1393 (6.8) 96 (4.4) 0.65 (0.50–0.85)c 0.22 (0.17–0.29)c 0.30 (0.21–0.43)c
  OCD 94 (2.3) 41 (0.2) 204 (1.0) 13 (0.6) 10.48 2.30 (1.79–2.95)c 4.05 (2.20–7.44)c
(7.21–15.24)c
  Psychoses 70 (1.7) 77 (0.4) 178 (0.9) 15 (0.7) 4.83 (3.46–6.73)c 2.01 (1.52–2.66)c 2.36 (1.31–4.26)c
  Tic disorder 61 (1.48) 5 (0.02) 139 (0.7) 3 (0.1) 59.36 2.18 (1.61–2.97)c 7.08
(23.69–148.73)c (2.18–22.98)c
Medical conditionb
  Allergy and/or immune 666 (16.2) 2585 (12.5) 3220 (15.6) 500 (23.2) 1.33 (1.21–1.46)c 1.02 (0.93–1.12) 0.73 (0.63–0.84)c
  Allergic rhinitis 154 (3.7) 498 (2.4) 659 (3.2) 68 (3.2) 1.62 (1.35–1.96)c 1.13 (0.95–1.36) 1.24 (0.90–1.70)
  Atopic dermatitis and eczema 270 (6.6) 1081 (5.2) 1189 (5.8) 157 (7.3) 1.29 (1.12–1.48)c 1.08 (0.94–1.24) 1.00 (0.80–1.26)
  Autoimmune disorders 148 (3.6) 456 (2.2) 705 (3.4) 1427 (66.2) 1.57 (1.30–1.90)c 1.04 (0.87–1.25) NCe
  Drug allergy 83 (2.0) 226 (1.1) 464 (2.2) 95 (4.4) 1.69 (1.30–2.18)c 0.91 (0.72–1.16) 0.61 (0.44–0.85)c
  Cardiovascular 248 (6.0) 545 (2.6) 817 (4.0) 522 (24.2) 2.32 (1.98–2.71)c 1.52 (1.31–1.77)c 0.25 (0.21–0.30)c
  Dyslipidemia 133 (3.2) 148 (0.7) 288 (1.4) 398 (18.5) 4.88 (3.83–6.22)c 2.24 (1.81–2.77)c 0.18 (0.15–0.23)c
  Endocrine 127 (3.1) 199 (1.0) 349 (1.7) 1617 (75.0) 3.20 (2.54–4.04)c 1.87 (1.52–2.31)c NC
  Any endocrine without diabetesd 104 (2.5) 199 (1.0) 248 (1.2) 203 (9.4) 2.61 (2.04–3.34)c 2.16 (1.71–2.74)c 0.38 (0.29–0.49)c

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  Diabetes (types 1 and 2)d 25 (0.6) 0 (0.0) 107 (0.5) 1555 (72.1) —d 1.18 (0.76–1.83) —d
  Thyroid disease (including autoimmune thyroid) 66 (1.6) 116 (0.6) 133 (0.6) 132 (6.1) 2.70 (1.98–3.69)c 2.53 (1.87–3.42)c 0.33 (0.24–0.46)c
  Ear, nose, and throat 325 (7.9) 693 (3.4) 872 (4.2) 77 (3.6) 2.37 (2.06–2.72)c 1.93 (1.69–2.20)c 2.62 (2.00–3.43)c
  Hearing impairment 80 (1.9) 156 (0.8) 226 (1.1) 26 (1.2) 2.54 (1.93–3.35)c 1.80 (1.39–2.33)c 1.71 (1.06–2.76)c
  GI 446 (10.8) 1741 (8.4) 2568 (12.5) 542 (25.1) 1.29 (1.16–1.45)c 0.87 (0.78–0.97)c 0.44 (0.38–0.52)c
  Constipation 70 (1.7) 98 (0.5) 177 (0.9) 34 (1.6) 3.47 (2.53–4.75)c 2.05 (1.54–2.71)c 1.09 (0.70–1.71)
  Diarrhea 69 (1.7) 190 (0.9) 319 (1.6) 62 (2.9) 1.68 (1.27–2.23)c 1.10 (0.84–1.43) 0.66 (0.45–0.97)c
  Functional disorders 169 (4.1) 972 (4.7) 1442 (7.0) 245 (11.4) 0.84 (0.71–1.00) 0.58 (0.49–0.68)c 0.47 (0.38–0.59)c
  Gastroesophageal reflux disease 77 (1.9) 218 (1.1) 400 (1.9) 94 (4.4) 1.77 (1.36–2.32)c 0.99 (0.77–1.27) 0.58 (0.41–0.81)c
  Upper GI motility problems 73 (1.8) 273 (1.3) 498 (2.4) 164 (7.6) 1.30 (1.00–1.70)c 0.76 (0.59–0.97)c 0.25 (0.18–0.33)c
  Geneticf 133 (3.2) 81 (0.4) 163 (0.8) 26 (1.2) 7.66 (5.77–10.17)c 4.09 (3.23–5.17)c 3.26 (2.09–5.11)c
  Genitourinary and/or renal 172 (4.2) 953 (4.6) 1307 (6.3) 401 (18.6) 0.87 (0.74–1.03) 0.64 (0.55–0.76)c 0.30 (0.24–0.36)c

DAVIGNON et al
 TABLE 2  Continued
Condition n (%) aOR (95% CI)a
ASD, TC, ADHD, DM, ASD Versus TC ASD Versus ADHD ASD Versus DM
n = 4123 n = 20 615 n = 20 615 n = 2156
  Renal disorders 89 (2.2) 403 (1.9) 595 (2.9) 270 (12.5) 1.07 (0.84–1.35) 0.75 (0.59–0.94)c 0.24 (0.18–0.31)c
  Hematology and/or oncology 159 (3.9) 553 (2.7) 736 (3.6) 194 (9.0) 1.41 (1.17–1.69)c 1.09 (0.91–1.30) 0.64 (0.50–0.81)c
  Infectious disease 1731 (42.0) 8795 (42.7) 10 608 (51.5) 1249 (57.9) 0.92 (0.81–1.04) 0.64 (0.56–0.72)c 0.55 (0.45–0.67)c
  Bacterial 209 (5.1) 1138 (5.5) 1494 (7.2) 228 (10.6) 0.89 (0.76–1.04) 0.69 (0.59–0.80)c 0.56 (0.46–0.70)c
  Mycoses 215 (5.2) 1311 (6.4) 1729 (8.4) 247 (11.5) 1.12 (0.97–1.29) 0.87 (0.76–1.00) 0.60 (0.49–0.73)c
  Viral 54 (3.8) 335 (4.8) 456 (6.5) 81 (10.8) 0.80 (0.68–0.92)c 0.61 (0.53–0.71)c 0.46 (0.38–0.57)
  Ear infections 81 (5.8) 213 (3.0) 323 (4.6) 33 (4.4) 1.70 (1.48–1.95)c 1.26 (1.11–1.45)c 1.18 (0.94–1.49)

PEDIATRICS Volume 141, number s4, April

  GI 154 (3.7) 1324 (6.4) 1706 (8.3) 171 (7.9) 0.54 (0.45–0.64)c 0.44 (0.37–0.52)c 0.43 (0.33–0.54)c
159 (3.9) 633 (3.1) 914 (4.4) 146 (6.8) 1.20 (1.01–1.44)c 0.86 (0.72–1.02) 0.54 (0.42–0.70)c

2018
  Lower respiratory
  Skin infections 403 (9.8) 1685 (8.2) 2239 (10.9) 374 (17.4) 1.14 (1.01–1.28)c 0.89 (0.80–1.00) 0.59 (0.50–0.69)

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  Upper respiratory infections 788 (19.1) 3996 (19.4) 5217 (25.3) 581 (27.0) 0.93 (0.85–1.01) 0.70 (0.64–0.76)c 0.72 (0.63–0.82)
  Injury 327 (7.9) 2240 (10.9) 3288 (16.0) 324 (15.0) 0.68 (0.60–0.77)c 0.47 (0.41–0.53)c 0.50 (0.42–0.60)c
  Fracture 237 (5.8) 1756 (8.5) 2500 (12.1) 260 (12.1) 0.64 (0.55–0.74)c 0.45 (0.40–0.52)c 0.47 (0.38–0.58)c
  Injury of head and neck 124 (3.0) 755 (3.7) 1253 (6.1) 95 (4.4) 0.77 (0.63–0.93)c 0.49 (0.41–0.60)c 0.63 (0.47–0.85)c
  Metabolic 143 (3.5) 200 (1.0) 345 (1.7) 392 (18.2) 3.71 (2.97–4.64)c 2.06 (1.68–2.52)c 0.21 (0.17–0.26)c
  Lipoid metabolism 100 (2.4) 100 (0.5) 199 (1.0) 297 (13.8) 5.35 (4.02–7.13)c 2.42 (1.89–3.10)c 0.21 (0.16–0.27)c
  Musculoskeletal 608 (14.8) 3726 (18.1) 4770 (23.1) 482 (22.4) 0.74 (0.67–0.81)c 0.59 (0.53–0.64)c 0.67 (0.58–0.78)c
  Neurology 733 (17.8) 1886 (9.2) 2909 (14.1) 470 (21.8) 2.07 (1.88–2.27)c 1.36 (1.24–1.49)c 1.03 (0.89–1.18)
  Cerebral palsy and other paralytic syndromes 93 (2.3) 60 (0.3) 104 (0.5) 14 (0.6) 7.37 (5.29–10.29)c 4.65 (3.50–6.19)c 4.94 (2.73–8.93)c
  Epilepsy and recurrent seizures 352 (8.5) 160 (0.8) 364 (1.8) 64 (3.0) 11.88 5.27 (4.52–6.14)c 4.10 (3.07–5.48)c
(9.78–14.43)c
  Hereditary and degenerative diseases of CNS 112 (2.7) 512 (2.5) 861 (4.2) 119 (5.5) 1.03 (0.84–1.28) 0.65 (0.54–0.80)c 0.62 (0.46–0.82)c
  Migraine 106 (2.6) 599 (2.9) 950 (4.6) 133 (6.2) 0.79 (0.64–0.98)c 0.57 (0.46–0.70)c 0.58 (0.44–0.78)c
  Syncope 82 (2.0) 274 (1.3) 434 (2.1) 45 (2.1) 1.43 (1.11–1.84)c 0.96 (0.75–1.22) 1.06 (0.71–1.59)
  Nutrition 214 (5.2) 395 (1.9) 637 (3.1) 156 (7.24) 2.84 (2.38–3.38)c 1.70 (1.45–2.00)c 0.95 (0.75–1.20)
  Nutrition metabolism and development 180 (4.4) 329 (1.6) 529 (2.6) 94 (4.4) 2.81 (2.32–3.39)c 1.71 (1.44–2.04)c 1.22 (0.92–1.61)
  Overweight and obesity 1821 (44.2) 6646 (32.2) 7653 (37.1) 1211 (56.2) 1.73 (1.62–1.86)c 1.37 (1.28–1.47)c 0.78 (0.70–0.88)c
  Overweight 784 (19.0) 3482 (16.9) 3751 (18.2) 535 (24.8) 1.16 (1.06–1.27)c 1.05 (0.96–1.15) 0.76 (0.66–0.87)c
  Obesity 1037 (25.2) 3164 (15.4) 3902 (18.9) 676 (31.4) 1.96 (1.81–2.13)c 1.49 (1.38–1.62)c 0.94 (0.83–1.07)
  Ophthalmology 164 (4.0) 642 (3.1) 672 (3.3) 170 (7.9) 1.33 (1.12–1.59)c 1.13 (0.95–1.35) 0.57 (0.44–0.72)c
  Pulmonary 383 (9.3) 1578 (7.6) 2582 (12.5) 313 (14.5) 1.19 (1.06–1.34)c 0.72 (0.64–0.81) 0.66 (0.55–0.78)
  Asthma 318 (7.7) 1306 (6.3) 2267 (11.0) 250 (11.6) 1.19 (1.04–1.35)c 0.68 (0.60–0.76) 0.68 (0.56–0.82)

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  Sleep 256 (6.2) 413 (2.0) 1057 (5.1) 131 (6.1) 3.13 (2.66–3.68)c 1.26 (1.09–1.45)c 1.24 (0.98–1.57)
  Dyssomnia 215 (5.2) 356 (1.7) 928 (4.5) 99 (4.6) 2.98 (2.50–3.56)c 1.21 (1.03–1.41)c 1.40 (1.07–1.82)c
  Smoking 235 (5.7) 2463 (12.0) 4447 (21.6) 386 (17.9) 0.40 (0.35–0.47)c 0.20 (0.18–0.24)c 0.28 (0.23–0.34)c
CNS, central nervous system; NC, not calculated; OCD, obsessive-compulsive disorder; —, not applicable.
a All analyses were adjusted for sex, age, race, and months of KPNC membership.
b For the developmental disabilities category, individual conditions are listed if they had a prevalence of at least 0.5% in the ASD group. For all psychiatric and medical condition categories, individual conditions are listed if they had a prevalence of

at least 1.5% in the ASD group and statistically significant findings in comparison with at least 1 comparison group (P < .05).
c Statistically significant odds ratio.
d The TC group was selected from among those who did not have an ADHD diagnosis and did not have a diabetes diagnosis; thus, comparisons between the ASD group and the TC group are not possible for these 2 conditions.
e NC because the regression model did not converge.
f Diagnosed at any time through September 2015.

S339
FIGURE 1
Percentage of psychiatric and medical conditions in 14- to 25-year-old individuals with ASD, ADHD, DM, and TCs, from KPNC, 2014–2015. A, Allergy and/or
Immune; B, Cardiovascular; C, Ear, Nose, and Throat; D, GI; E, Infectious Disease; F, Injury; G, Musculoskeletal; H, Neurology; I, Overweight and/or Obesity;
J, Psychiatric; K, Pulmonary; L, Sleep. * denotes a statistically significant difference compared with the ASD group.

disorders of the nervous system following notable exceptions: (asthma) were all significantly
occurred at equal frequency in allergy and/or immunology less prevalent in the comparisons
the ASD and TC groups; injury, conditions, diabetes, diarrhea, between the ASD group versus the
musculoskeletal conditions, and gastroesophageal reflux, hematology ADHD group (‍Table 2).
migraines were significantly less and/or oncology, overweight, and By contrast, compared with the DM
common in the ASD group versus the ophthalmologic conditions did not group, individuals with ASD were at
TC group (‍Table 2). differ in frequency between the a similar or significantly lower risk
Comparisons between the ASD ASD group and the ADHD group. GI of most medical conditions, with the
and ADHD groups were largely disorders, genitourinary and/or renal exception of hearing impairment,
similar to those between the ASD conditions, infectious diseases as a genetic disorders, cerebral palsy,
group and the TC group, with the group, and pulmonary conditions epilepsy, and dyssomnia, all of which

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were significantly more common reason for the lower prevalence been reported previously in other
in the ASD group compared with may be that ID is typically identified populations of teenagers and adults
the DM group (‍Table 2). Smoking and treated in school or community with ASD .‍4,​11 On a positive note,
was significantly less common in settings and thus not routinely noted individuals with ASD had lower drug
individuals with ASD than in each in medical records. Prevalence of ID abuse and smoking rates, consistent
comparison group (‍Table 2). did increase with age, and our finding with previous reports.‍4,​15
‍ Because
Additional adjustment for the of 19% ID among 22- to 25-year- these often begin as social behaviors,
number of outpatient visits resulted olds is consistent with our previous the difficulties with social cognition
in slightly attenuated risk estimates, finding among all adults ≥18 years seen in those with ASD may be
with only a few findings losing old, with a mean age of 29 years,​‍4 somewhat protective against these
statistical significance: allergy and/or perhaps because of the need for a conditions.
immunology (ASD versus DM), medical diagnosis of ID to qualify for
Our finding that most medical
GI (ASD versus TD), and asthma social security income.
conditions were more prevalent in
(ASD versus TD) (data not shown). Among individuals with language transition-aged individuals with ASD
or learning disorders diagnosed at than those in TC groups is similar to
Prevalence of Conditions by Age some point in the past, <2% had observations in children and adults.‍4,​16
‍
and Sex
documentation of these disorders in Obesity is interesting to consider
Among individuals with ASD, most the EMR during the transition years. in relation to other comorbidities
conditions increased with age Although language and learning observed in the ASD group. Obesity
(‍Fig 2). Infectious diseases and skills may improve with age and in children with ASD has been
injury decreased with age, and treatment, significant deficits persist linked to gross motor deficits
musculoskeletal disorders fluctuated for the majority of individuals.‍13,​14
‍ limiting physical activity and with
with age. For many conditions, age- Thus, it is suggested in our data that higher rates of poor sleep quality,
related changes in the comparison language and learning disabilities are constipation, selective eating, and
groups were in the same direction underrecognized in transition-aged other GI disturbances.‍17 In addition,
as the ASD group. Most conditions individuals with ASD. These DDs obesity has known associations with
were more common in females may impact the ability of patients several chronic medical conditions,
than males, with the largest sex to understand verbal and written including diabetes, hyperlipidemia,
differences observed for allergy information from medical providers hypertension, and cardiovascular
and/or immunologic conditions, and may contribute to behavioral and disease,​‍10 all of which were elevated
infections, musculoskeletal conditions, emotional difficulties.‍10 Recognizing in the ASD group.
neurologic conditions, and psychiatric and accommodating the learning and
Although GI and sleep conditions
conditions (‍Fig 3). For each major communication needs of individuals
were more common in transition-
comorbidity category, case-control with ASD is important for high-
aged individuals with ASD than
differences were in the same direction quality medical care.‍10
individuals in age-matched TC
for both males and females.
Approximately one-third of groups, prevalence was lower than
individuals with ASD had a previously reported for children
DISCUSSION psychiatric condition identified and adults with ASD.‍4,​18,​
‍ 19
‍ We also
during the study period, a rate lower observed a lower rate of migraines
In this large population of insured, than the 54% previously reported for in the ASD group versus comparison
transition-aged individuals, the KPNC adult population.‍4 Although groups, in contrast to a previous
psychiatric and medical conditions the prevalence of most psychiatric report in which authors indicated
were more prevalent in individuals conditions increased with age, the that children with autism are more
with ASD than in typical or ADHD rate in 22- to 25-year-olds was still likely than those without to have
controls, and most conditions lower than that reported among all had frequent severe headaches
increased with age and were more adults,​‍4 which is consistent with or migraines.‍16 Individuals with
common in females. expectations given that the typical ASD and GI problems, sleep
Among individuals with ASD, the age of onset for many conditions disorders, or headaches and/or
prevalence of ID (13.0%) was similar is in teen-aged and young adult migraines are more likely to have
to the 16% prevalence reported for years.‍1 Of concern was the almost irritability, challenging behavior,
another population with a median fourfold higher rate of suicide and social withdrawal, stereotypy,
age of 19 years,​‍11 although lower self-inflicted injury among transition- hyperactivity, inattention, and
than previous reports for younger aged individuals with ASD. Increased anxiety.18–‍ 20
‍ These symptoms
children‍2 and older adults.‍12 One risks of suicide and self-harm have may lead to psychiatric diagnoses

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FIGURE 2
Percentage of psychiatric and medical conditions by age in 14- to 25-year-old individuals with ASD, ADHD, DM, and TCs, from KPNC, 2014–2015. A, Allergy
and/or Immune; B, Cardiovascular; C, Ear, Nose, and Throat; D, GI; E, Infectious Disease; F, Injury; G, Musculoskeletal; H, Neurology; I, Overweight and/or
Obesity; J, Psychiatric; K, Pulmonary; L, Sleep. * denotes a statistically significant difference compared with the ASD group.

or treatment with psychotropic with children and adults, it is possible There are likely many contributors
medications, which in turn may that certain medical conditions are to the elevated rates of co-occurring
increase the risk of other health underrecognized and undertreated conditions seen in individuals
problems. Thus, although transition- in this age group, contributing to with ASD. Self-recognition of
aged individuals with ASD may additional medical, behavioral, and differences from others and social
experience relative health compared mental health problems. isolation may lead to anxiety and

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FIGURE 3
Percentage of psychiatric and medical conditions by sex in 14- to 25-year-old individuals with ASD, ADHD, DM, and TCs, from KPNC, 2014–2015. A, Allergy
and/or Immune; B, Cardiovascular; C, Ear, Nose, and Throat; D, GI; E, Infectious Disease; F, Injury; G, Musculoskeletal; H, Neurology; I, Overweight and/or
Obesity; J, Psychiatric; K, Pulmonary; L, Sleep. * denotes a statistically significant difference compared with the ASD group.

depression, and treatments used and GI problems. In addition, transitioning, changing routines, and
to address behavioral, psychiatric, symptoms inherent to ASD, accommodating to unfamiliar people
and neurologic conditions may including sensory sensitivities and places may make it more difficult
lead to or exacerbate other medical and difficulties describing feelings for teenagers and young adults with
conditions, such as obesity, sleep, and pain, interacting with others, ASD to access adequate medical

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care.‍10 Finally, clinical providers problems were captured. Although of medical and psychiatric issues,
may be unfamiliar with how to efforts were made to classify as is the standard of care for other
accommodate the unique needs of ICD-9 codes appropriately, chronic medical conditions.
transition-aged individuals with ASD, phenotypic categorization may
contributing to less successful office have resulted in occasional
visits.‍10,​21
‍ misclassification. ABBREVIATIONS
ADHD: attention-deficit/hyperac-
Our findings must be considered in
CONCLUSIONS tivity disorder
light of study limitations. To focus on
aOR: adjusted odds ratio
conditions for which transition-aged Psychiatric and medical
ASD: autism spectrum disorder
youth are actively being treated, comorbidities were common in
CI: confidence interval
diagnoses were identified only over this large, insured population of
DD: developmental disorder
a 2-year time period, potentially transition-aged individuals with ASD.
DM: diabetes mellitus
resulting in underascertainment Although more research is needed
EMR: electronic medical record
of chronic conditions that are well to identify the intrinsic and extrinsic
GI: gastrointestinal
controlled and require infrequent factors that contribute to this excess
ICD-9: International Classification
visits. However, all included burden, there is a pressing need for
of Diseases, Ninth Revision
participants were members of KPNC all clinicians, particularly general
ID: intellectual disability
for at least 9 months out of 1 year pediatricians and adult physicians,
KPNC: Kaiser Permanente
during the 2-year study period to approach ASD as a chronic health
Northern California
and the previous year, making it condition requiring regular follow-up
TC: typical control
highly probable that active medical and routine screening and treatment

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by Autism Speaks and the Working for Inclusive and Transformative Healthcare Foundation.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Psychiatric and Medical Conditions in Transition-Aged Individuals With ASD
Meghan N. Davignon, Yinge Qian, Maria Massolo and Lisa A. Croen
Pediatrics 2018;141;S335
DOI: 10.1542/peds.2016-4300K

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Psychiatric and Medical Conditions in Transition-Aged Individuals With ASD
Meghan N. Davignon, Yinge Qian, Maria Massolo and Lisa A. Croen
Pediatrics 2018;141;S335
DOI: 10.1542/peds.2016-4300K

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
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