Prevalence and Early Identification of Autism Spectrum Disorder Among Children Aged 4 and 8 Years — Autism and Developmental Disabilities Monitoring Network, 16 Sites, United States, 2022

Kelly Shaw; Susan P. Williams; Mary Patrick; Miguel Valencia‐Prado; Maureen S. Durkin

doi:10.15585/mmwr.ss7402a1

Prevalence and Early Identification of Autism Spectrum Disorder Among Children Aged 4 and 8 Years — Autism and Developmental Disabilities Monitoring Network, 16 Sites, United States, 2022

Kelly Shaw, Susan P. Williams, Mary Patrick, Miguel Valencia‐Prado, Maureen S. Durkin, Ellen M. Howerton, Christine M. Ladd-Acosta, Elise T. Pas, Amanda V. Bakian, Paul Bartholomew, Nancy Nieves-Muñoz, Kate Sidwell, Amy Alford, Deborah A. Bilder, Monica DiRienzo...

Centers for Disease Control and Prevention (2025) • Volume 74, Issue 2, Pages 1-22

Empirical-ClinicalCrossSectionalPDF AvailableGrade Eligible

Overall Assessment

Adequate Methodological Quality

Assessment created by PaperScorers Medical AI v0.1.0 on Dec 22, 2025

C

64/100

Key Takeaways

•ASD prevalence among 8-year-olds in 2022 was 32.2/1,000 (1 in 31), varying 9.7–53.1 across sites.
•Higher prevalence in A/PI, Black, Hispanic vs White; male:female ratio 3.4.
•Cumulative incidence by 48 months was 1.7x higher for 2018 births vs 2014 births.
•Co-occurring intellectual disability among ASD with IQ data: 39.6% overall.
•Site practices varied widely in diagnostic statements, education eligibility, ICD coding, and testing.

Conclusion

Robust multi-source surveillance shows increasing ASD prevalence and earlier identification, with marked inter-site variability and disparities by race/ethnicity.

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Quality Dimensions

Bias & Integrity

COI handling, outcome switching, selective reporting

B75

Methods Rigour

Protocol clarity, sampling, controls

B78

External Validity

Generalisability, setting, population

C+65

Transparency & Reproducibility

Data/code/materials availability, preregistration

F20

Significance & Novelty

Contribution vs prior art; context if known

B-72

Statistical Validity

Models, assumptions, multiplicity, CI priority

B-70

Integrity & Transparency

Integrity checks

P-hacking risk?

?

None suspected

Signs of selective hypothesis testing or analysis choices that could inflate false positive rates.

Outcome switching?

?

None suspected

Evidence that primary outcomes were changed during or after the study, potentially distorting results.

Conflict of interest?

?

None suspected

Authors have financial or other relationships that could bias research findings.

Data integrity issues?

?

None suspected

Concerns about the accuracy, completeness, or authenticity of the reported data.

Open science signals

Research data

?

Not shared

Raw data used in the analyses is publicly available or accessible upon request.

Analysis code

?

Not shared

Code or scripts used to analyze the data are shared for reproducibility.

Study materials

?

Not applicable

Protocols, questionnaires, and other materials are publicly available.

Premise

Primary Research Question

What are 2022 ASD prevalence and early identification patterns among children aged 4 and 8 years across 16 ADDM sites?

Hypothesis is Falsifiable

—Not specified

Descriptive surveillance; no formal hypothesis.

PICO Framework

Population✓Yes

Children aged 4 and 8 residing in defined surveillance areas in 2022.

Intervention—Not specified

No intervention in surveillance.

Comparison✓Yes

Comparisons by sex, race/ethnicity, MHI/SVI, and birth cohorts are prespecified.

Outcome✓Yes

ASD prevalence, cumulative incidence, age at diagnosis, co-occurring ID.

Literature Positioning

Literature Review Balanced

Well covered

Situates findings vs prior ADDM cycles and external datasets (NHIS, CA DDS, England).

Evidence: Discussion; Refs 22–25

Research Gap Clearly Stated

Well covered

States need to monitor trends and early equitable identification; expansion to 16 sites.

Evidence: Introduction p.2–3

Stated Contribution Clear

Well covered

Provides 2022 ASD prevalence and early identification patterns for 4- and 8-year-olds across 16 sites.

Evidence: Abstract p.1; Introduction p.2

Study Provenance

Peer review unclearFunding not reportedConflicts disclosedAffiliations listed

Authors & Affiliations

CDC NCBDDD and multiple universities/state agencies across 16 US sites and Puerto Rico.

Funding Statement

Not reported

Conflicts of Interest

Conflict of Interest section lists limited personal consultancies/honoraria for a few authors; others none declared.

Peer Review

?MMWR Surveillance Summaries; internal editorial board listed; external peer review not specified.

Evidence: p. i MMWR Editorial Board

Methodological Assessment

Public Health SurveillanceSurveillance

15 applicable checklist items.

Yes 10 · No 2 · Unclear 3

Data Sources & Coverage

✓

Data Sources Enumerated

Health/education/early intervention/Medicaid/state services sources listed by site.

Evidence: Table 1; Methods p.3–4

?

Geographic Coverage Adequate

16 diverse sites but not nationally representative; some partial school coverage.

Evidence: Table 1 (education coverage %); Limitations p.14

✓

Denominator Population Stated

Denominators from US Census Vintage 2022 and ACS for tract-adjusted areas.

Evidence: Methods p.3–4

✓

Coverage Completeness Reported

% education coverage and % with records abstracted reported by site.

Evidence: Table 1

Definitions & Standards

✓

Case Definitions Standardised

Uniform ASD case definition using diagnostic statements, special ed eligibility, or ICD codes.

Evidence: Methods p.3–4

✓

Subgroup Definitions Clear

Clear definitions for sex, race/ethnicity, AI/AN, A/PI, Hispanic; PR handling stated.

Evidence: Analytic Methods p.4–5; Table 2 notes

Analysis & Methods

?

Reporting Delay Adjustment

No explicit adjustment for reporting delays described.

✓

Trend Method Specified (e.g., Joinpoint)

Trend testing via Cochran-Armitage; no Joinpoint used.

Evidence: Analytic Methods p.5; Fig.1

✓

Uncertainty Intervals Reported

95% CIs and Bayesian credible intervals reported; RSE-based suppression applied.

Evidence: Results p.5–6; Fig.1; Supp. Methods 2

✓

Comparability Over Time Addressed

2020 vs 2022 comparisons with boundary/data-source caveats provided.

Evidence: Results p.5–6; Supp. Table 2

Transparency & Validation

✗

Data Access Statement

No data access statement or repository provided.

✗

Code/Workflow Available

No code or workflow repository provided.

?

QA/QC Procedures Described

Some methodological QA (suppression, linkage), but no explicit QA/QC protocol.

Evidence: Methods p.3–5

✓

External Validation/Comparison

Patterns compared to NHIS, CA DDS, England datasets in Discussion.

Evidence: Discussion; Refs 23–25

✓

Bias & Limitations Discussed

Limitations detail representativeness, data completeness, and source gaps.

Evidence: Limitations p.14

Modules without applicable checklist items (9)

These designs were fully marked as not applicable but remain available for reference.

Abstract

Increased identification of autism, particularly among very young children and previously underidentified groups, underscores the increased demand and ongoing need for enhanced planning to provide equitable diagnostic, treatment, and support services for all children with ASD. The substantial variability in ASD identification across sites suggests opportunities to identify and implement successful strategies and practices in communities to ensure all children with ASD reach their potential.

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Study Overview

Study Design

Cross Sectional

Primary classification used to evaluate this research.

Population

Children aged 4 and 8 years residing in 16 ADDM Network surveillance areas in the United States during 2022.

Brief summary of who or what was studied.

Pre-registration

Not registered

Indicates whether the protocol or trial was registered before data collection.

Randomisation

None reported

How participants were allocated to groups: None (no randomisation), Simple (random order), Blocked (groups balanced in blocks), Stratified (balanced within subgroups), Adaptive (allocation adjusted based on previous enrollments).

Blinding

None

Who was unaware of group assignments: None (everyone knew), Single blind (participants didn't know their group), Double blind (participants and researchers didn't know), Triple blind (also outcome assessors didn't know).

Follow-up

not-applicable

Duration of observation or follow-up for outcomes.

Primary Outcome

Primary outcome was pre-specified in the protocol or registry.

Effect Size

Prevalence per 1,000: 32.2 (95% CI 31.6–32.9) among 8-year-olds

Reviewer Notes

Active record-linkage surveillance; cross-sectional prevalence with cohort (2014 vs 2018 births) cumulative incidence comparisons.

Publication Details

DOI

10.15585/mmwr.ss7402a1

Published

April 15, 2025

Citations

205 citations

FWCI

837.18

External Resources

DOI Link OpenAlex

Disclaimer: This assessment is generated by AI and should not be the sole basis for clinical or research decisions. Always review the original paper and consult with domain experts.

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