Autistic children and children with attention-deficit/hyperactivity disorder (ADHD) may have more frequent visits to the emergency department (ED). We aim to identify the primary reasons for ED visits among autistic children and children with ADHD, compared to a random sample of visits.
Using 2008 to 2017 Nationwide Emergency Department Sample data, we assessed the most frequent primary diagnoses for ED visits among children (ages 3–12 and 13–18 years, separately) (1) with an autism diagnosis, (2) with ADHD, and (3) a random sample (1 000 000 visits). We regressed primary reasons for visits on autism or ADHD diagnosis, controlling for individual characteristics, to assess the odds of presenting for these reasons.
Although the 10 most frequent diagnoses among the random sample were physical health conditions, autistic children and children with ADHD often presented for psychiatric conditions. Older children with autism and with ADHD more frequently presented for mood disorders (10%–15% of visits; odds ratios [ORs] = 5.2–8.5) and intentional self-harm (ORs = 3.2–5.0). Younger children with ADHD more commonly presented with mood disorders (6.6% of visits; OR = 18.3) and younger autistic children more often presented with attention-deficit, conduct, and disruptive behavior disorders (9.7% of visits; OR = 9.7).
Autistic children and children with ADHD have higher odds of presenting to the ED for psychiatric conditions than a random sample, including for self-harm. Clinicians should treat these populations sensitively, recognize and assess the risk for self-harm, and facilitate continuing psychiatric care.
Autistic hildren and children with developmental disabilities have more emergency department visits than neurotypical children, and mental health reasons drive many visits for adolescents. Emergency department visits for mental health conditions have been increasing over the last decade.
Mood disorders and behavioral concerns drive many visits to the emergency department among autistic children and children with ADHD; suicidal ideation or intentional self-harm is a main presenting diagnosis among adolescents. Risk assessment and follow-up psychiatric care may be necessary.
Autism spectrum disorder (ASD) is the fastest-growing developmental disability in the United States, reaching a prevalence of 1 in 54 in 2020,1 and attention-deficit hyperactivity disorder (ADHD) is the most prevalent developmental disability, diagnosed for 9.5% of children in 2017.2 Research suggests that visits to the emergency department (ED) among children with developmental disabilities like these may be more frequent than for their neurotypical peers.3–5
In some cases, children with developmental disabilities may present to the ED when psychiatric care needs are not otherwise met.6 In fact, psychiatric diagnoses drive many ED visits among autistic youth ages 12 to 15.7 Such visits have risen substantially over the last decade for children with mental health diagnoses, and visits for intentional self-harm have also increased.8 Although we know psychiatric diagnoses are more common among children with developmental disabilities, it is not clear how often they are the leading causes of presentation to the ED. We examined primary reasons for ED visits among children ages 3 to 18 with diagnoses of ASD or ADHD to assess whether psychiatric conditions were among the top 10 reasons for ED visits and whether the top 10 reasons differed from a random sample of visits over the period 2008 to 2017.
Methods
We used 2008 to 2017 data from the Nationwide Emergency Department Sample (NEDS), which contains data for > 30 million annual ED visits. All analyses were based on weighted data adjusted for complex survey design to produce nationwide visits-level statistics with ED visits as the unit of analysis
Patient Characteristics
We used Clinical Classification Software (CCS), which classifies International Classification of Diseases, 9th Revision (ICD-9) and 10th Revision (ICD-10) diagnoses into clinically relevant categories. We defined 2 diagnostic groups of children ages 3 to 18 years by developmental disorder: (1) autism (ICD-9 = 299.xx, ICD-10 = F84.x) and (2) ADHD (attention-deficit, conduct, and disruptive behavior disorders, CCS = 652). Visits were assigned to the corresponding group if any diagnosis of that condition was coded, regardless of the order in which it was coded (up to 35 diagnoses were allowed). The primary reason for presentation at the ED was identified with the primary diagnosis coded. When the primary diagnosis was the same as the developmental disability group into which the child was classified, we recoded the primary reason as the secondary diagnosis. We also examined primary reasons for ED visits for a random sample of visits of children 3 to 18 years old (with or without developmental disabilities, n = 1 000 000). Controls included age (in integers), sex, region, health plan type, residence type, income quartile, and ED “disposition” (eg, transfer or inpatient admission).
Analysis
We calculated descriptive statistics and then sorted primary diagnoses in order of frequency to rank the 20 most frequent reasons for ED presentation within each group. We conducted logistic regressions of primary diagnosis on diagnostic group and controls, estimating odds ratios (ORs) for each diagnostic group compared with the random sample, separately for each group.
Results
Nationwide, there were an estimated 20 338 690 annual pediatric (ages 3–18) ED visits on average for the period 2008 to 2017. Of these, 107 337 (0.5%) were for autistic patients and 448 094 (2.2%) were for patients with ADHD. In 2017, these values were 0.8% and 2.5% of total visits, respectively.
Patients with 1 of these 2 developmental disabilities had higher rates of transfer and inpatient admission than the general population; 13.9% (autism) and 13.1% (ADHD) were admitted to inpatient, and 5.9% and 7.9%, respectively, transferred to other facilities (compared with 3.3% admitted to inpatient, 2.1% transferred in the random sample) (Table 1). The proportion of visits for psychiatric conditions increased for the autism and ADHD groups yet remained relatively stable in the random sample.
Individual Characteristics, Autistic Patients, Patients with ADHD, and Random Sample
. | Autism (n = 237 154) . | ADHD (n = 985 432) . | Random Sample (n = 1 000 000) . | |||||
---|---|---|---|---|---|---|---|---|
. | Est. Pop. n . | % . | P . | Est. Pop. n . | % . | P . | Est. Pop. n . | % . |
Age group, y | ||||||||
3–12 | 70 677 | 65.8 | <.0001 | 218 971 | 48.9 | <.0001 | 266 792 | 59.7 |
13–18 | 36 660 | 34.2 | <.0001 | 229 123 | 51.1 | <.0001 | 180 294 | 40.3 |
Sex | ||||||||
Male | 85 705 | 79.8 | <.0001 | 300 359 | 67.0 | <.0001 | 224 420 | 50.2 |
Female | 21 619 | 20.1 | <.0001 | 147 668 | 33.0 | <.0001 | 222 561 | 49.8 |
Missing | 13 | 0.0 | — | 66 | 0.0 | — | 105 | 0.0 |
Hospital region | ||||||||
Northeast | 25 689 | 23.9 | <.0001 | 98 077 | 21.9 | .0009 | 84 087 | 18.8 |
Midwest | 23 461 | 21.9 | .0391 | 116 197 | 25.9 | .0205 | 105 582 | 23.6 |
South | 34 929 | 32.5 | <.0001 | 186 891 | 41.7 | .0051 | 171 780 | 38.4 |
West | 23 259 | 21.7 | .0020 | 46 929 | 10.5 | <.0001 | 85 638 | 19.2 |
Primary payer | ||||||||
Public | 62 807 | 58.5 | <.0001 | 274 191 | 61.2 | <.0001 | 234 932 | 52.5 |
Private including HMO | 37 039 | 34.5 | .0044 | 139 909 | 31.2 | <.0001 | 159 156 | 35.6 |
Self-pay | 2954 | 2.8 | <.0001 | 17 312 | 3.9 | <.0001 | 34 789 | 7.8 |
No charge | 4400 | 4.1 | .1070 | 15 896 | 3.5 | .0054 | 17 220 | 3.9 |
Missing | 137 | 0.1 | — | 786 | 0.2 | — | 990 | 0.2 |
Residence | ||||||||
Large central metropolitan | 32 212 | 30.0 | .0128 | 105 848 | 23.6 | <.0001 | 124 244 | 27.8 |
Large fringe metropolitan | 25 805 | 24.0 | .0018 | 100 924 | 22.5 | .3835 | 97 907 | 21.9 |
Medium metropolitan | 25 136 | 23.4 | .0451 | 113 776 | 25.4 | <.0001 | 97 310 | 21.8 |
Small metropolitan | 9518 | 8.9 | .1274 | 47 199 | 10.5 | .0198 | 41 943 | 9.4 |
Micropolitan | 9506 | 8.9 | <0001 | 53 421 | 11.9 | .1058 | 50 278 | 11.2 |
Rural | 4839 | 4.5 | <.0001 | 25 597 | 5.7 | <.0001 | 33 868 | 7.6 |
Missing | 321 | 0.3 | — | 1329 | 0.3 | — | 1536 | 0.3 |
Disposition type | ||||||||
Routine | 84 584 | 78.8 | <.0001 | 346 942 | 77.4 | <.0001 | 414 087 | 92.6 |
Transfer | 6329 | 5.9 | <.0001 | 35 366 | 7.9 | <.0001 | 9253 | 2.1 |
Inpatient admission | 14 955 | 13.9 | <.0001 | 58 507 | 13.1 | <.0001 | 14 881 | 3.3 |
Other | 1469 | 1.4 | <.0001 | 7278 | 1.6 | .0536 | 8866 | 2.0 |
Income level | ||||||||
Q1 (low) | 29 054 | 27.1 | <.0001 | 144 999 | 32.4 | .1267 | 148 323 | 33.2 |
Q2 | 27 709 | 25.8 | .0003 | 122 565 | 27.4 | .4189 | 120 924 | 27.0 |
Q3 | 25 416 | 23.7 | <.0001 | 96 679 | 21.6 | .9221 | 96 591 | 21.6 |
Q4 (high) | 23 483 | 21.9 | <.0001 | 76 281 | 17.0 | .3787 | 74 435 | 16.6 |
Missing | 1675 | 1.6 | — | 7570 | 1.7 | — | 6813 | 1.5 |
Year | ||||||||
2008 | 6181 | 5.8 | <.0001 | 34 475 | 7.7 | <.0001 | 42 792 | 9.6 |
2009 | 6825 | 6.4 | <.0001 | 39 497 | 8.8 | <.0001 | 46 718 | 10.4 |
2010 | 7226 | 6.7 | <.0001 | 38 120 | 8.5 | .0024 | 42 584 | 9.5 |
2011 | 9085 | 8.5 | <.0001 | 46 294 | 10.3 | .4205 | 44 578 | 10.0 |
2012 | 9979 | 9.3 | .0075 | 46 813 | 10.4 | .6732 | 45 994 | 10.3 |
2013 | 10 792 | 10.1 | .7722 | 47 599 | 10.6 | .1625 | 44 369 | 9.9 |
2014 | 12 852 | 12.0 | <.0001 | 49 076 | 11.0 | .0267 | 43 846 | 9.8 |
2015 | 13 161 | 12.3 | .0001 | 48 582 | 10.8 | .2145 | 45 734 | 10.2 |
2016 | 14 855 | 13.8 | <.0001 | 46 858 | 10.5 | .9096 | 46 527 | 10.4 |
2017 | 16 381 | 15.3 | <.0001 | 50 782 | 11.3 | .0035 | 43 944 | 9.83 |
. | Autism (n = 237 154) . | ADHD (n = 985 432) . | Random Sample (n = 1 000 000) . | |||||
---|---|---|---|---|---|---|---|---|
. | Est. Pop. n . | % . | P . | Est. Pop. n . | % . | P . | Est. Pop. n . | % . |
Age group, y | ||||||||
3–12 | 70 677 | 65.8 | <.0001 | 218 971 | 48.9 | <.0001 | 266 792 | 59.7 |
13–18 | 36 660 | 34.2 | <.0001 | 229 123 | 51.1 | <.0001 | 180 294 | 40.3 |
Sex | ||||||||
Male | 85 705 | 79.8 | <.0001 | 300 359 | 67.0 | <.0001 | 224 420 | 50.2 |
Female | 21 619 | 20.1 | <.0001 | 147 668 | 33.0 | <.0001 | 222 561 | 49.8 |
Missing | 13 | 0.0 | — | 66 | 0.0 | — | 105 | 0.0 |
Hospital region | ||||||||
Northeast | 25 689 | 23.9 | <.0001 | 98 077 | 21.9 | .0009 | 84 087 | 18.8 |
Midwest | 23 461 | 21.9 | .0391 | 116 197 | 25.9 | .0205 | 105 582 | 23.6 |
South | 34 929 | 32.5 | <.0001 | 186 891 | 41.7 | .0051 | 171 780 | 38.4 |
West | 23 259 | 21.7 | .0020 | 46 929 | 10.5 | <.0001 | 85 638 | 19.2 |
Primary payer | ||||||||
Public | 62 807 | 58.5 | <.0001 | 274 191 | 61.2 | <.0001 | 234 932 | 52.5 |
Private including HMO | 37 039 | 34.5 | .0044 | 139 909 | 31.2 | <.0001 | 159 156 | 35.6 |
Self-pay | 2954 | 2.8 | <.0001 | 17 312 | 3.9 | <.0001 | 34 789 | 7.8 |
No charge | 4400 | 4.1 | .1070 | 15 896 | 3.5 | .0054 | 17 220 | 3.9 |
Missing | 137 | 0.1 | — | 786 | 0.2 | — | 990 | 0.2 |
Residence | ||||||||
Large central metropolitan | 32 212 | 30.0 | .0128 | 105 848 | 23.6 | <.0001 | 124 244 | 27.8 |
Large fringe metropolitan | 25 805 | 24.0 | .0018 | 100 924 | 22.5 | .3835 | 97 907 | 21.9 |
Medium metropolitan | 25 136 | 23.4 | .0451 | 113 776 | 25.4 | <.0001 | 97 310 | 21.8 |
Small metropolitan | 9518 | 8.9 | .1274 | 47 199 | 10.5 | .0198 | 41 943 | 9.4 |
Micropolitan | 9506 | 8.9 | <0001 | 53 421 | 11.9 | .1058 | 50 278 | 11.2 |
Rural | 4839 | 4.5 | <.0001 | 25 597 | 5.7 | <.0001 | 33 868 | 7.6 |
Missing | 321 | 0.3 | — | 1329 | 0.3 | — | 1536 | 0.3 |
Disposition type | ||||||||
Routine | 84 584 | 78.8 | <.0001 | 346 942 | 77.4 | <.0001 | 414 087 | 92.6 |
Transfer | 6329 | 5.9 | <.0001 | 35 366 | 7.9 | <.0001 | 9253 | 2.1 |
Inpatient admission | 14 955 | 13.9 | <.0001 | 58 507 | 13.1 | <.0001 | 14 881 | 3.3 |
Other | 1469 | 1.4 | <.0001 | 7278 | 1.6 | .0536 | 8866 | 2.0 |
Income level | ||||||||
Q1 (low) | 29 054 | 27.1 | <.0001 | 144 999 | 32.4 | .1267 | 148 323 | 33.2 |
Q2 | 27 709 | 25.8 | .0003 | 122 565 | 27.4 | .4189 | 120 924 | 27.0 |
Q3 | 25 416 | 23.7 | <.0001 | 96 679 | 21.6 | .9221 | 96 591 | 21.6 |
Q4 (high) | 23 483 | 21.9 | <.0001 | 76 281 | 17.0 | .3787 | 74 435 | 16.6 |
Missing | 1675 | 1.6 | — | 7570 | 1.7 | — | 6813 | 1.5 |
Year | ||||||||
2008 | 6181 | 5.8 | <.0001 | 34 475 | 7.7 | <.0001 | 42 792 | 9.6 |
2009 | 6825 | 6.4 | <.0001 | 39 497 | 8.8 | <.0001 | 46 718 | 10.4 |
2010 | 7226 | 6.7 | <.0001 | 38 120 | 8.5 | .0024 | 42 584 | 9.5 |
2011 | 9085 | 8.5 | <.0001 | 46 294 | 10.3 | .4205 | 44 578 | 10.0 |
2012 | 9979 | 9.3 | .0075 | 46 813 | 10.4 | .6732 | 45 994 | 10.3 |
2013 | 10 792 | 10.1 | .7722 | 47 599 | 10.6 | .1625 | 44 369 | 9.9 |
2014 | 12 852 | 12.0 | <.0001 | 49 076 | 11.0 | .0267 | 43 846 | 9.8 |
2015 | 13 161 | 12.3 | .0001 | 48 582 | 10.8 | .2145 | 45 734 | 10.2 |
2016 | 14 855 | 13.8 | <.0001 | 46 858 | 10.5 | .9096 | 46 527 | 10.4 |
2017 | 16 381 | 15.3 | <.0001 | 50 782 | 11.3 | .0035 | 43 944 | 9.83 |
Source: Authors’ calculations from NEDS data, 2008–2017. Est. Pop. N = weighted estimate of the population of this group among ED visits in the United States; Est. Pop. % = weighted estimate of the percentage of this group among ED visits in the United States figures for the random sample do not represent the entire United States; it is random sample of 1 000 000 visits. P values represent χ2s for row differences between the diagnostic group and the random sample..
Physical Conditions
Among the random sample of pediatric visits of both younger and older children, the 10 most frequent primary diagnoses were physical conditions (Tables 2 and 3). Among visits of younger autistic children, the top 10 physical conditions differed from the random sample for the following conditions: epilepsy and convulsions (6.4% of visits), other gastrointestinal disorders (3.4% of visits), and nausea and vomiting (3.1% of visits). For older autistic children, the top 10 reasons for presentation included epilepsy and convulsions (8.8% of visits), which was not a top 10 condition in the random sample. Among visits of younger children with ADHD, a top 10 condition for presentation not as common in the random sample was “open wounds of extremities;” among older children with ADHD, there were no physical conditions that did not appear in the top 10 conditions of the random sample.
Most Frequent Reasons for ED Visits, % of Visits, and Odds Ratios by Age (3–12) and Diagnostic Group
. | Autism (n = 156 381) . | ADHD (n = 482 358) . | Random Sample (n = 597 777) . | |||||
---|---|---|---|---|---|---|---|---|
Rank . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . |
1 | Other upper respiratory infections | 7.7 | 0.65 (0.62–0.68) | Mood disordersa | 6.6 | 18.30 (16.55–20.24) | Other upper respiratory infections | 12.1 |
2 | Epilepsy; convulsions | 6.3 | 8.27 (7.71–8.87) | Superficial injury; contusion | 6.0 | 0.76 (0.73–0.80) | Superficial injury; contusion | 6.7 |
3 | Superficial injury; contusion | 5.0 | 0.71 (0.68–0.74) | Other upper respiratory infections | 5.8 | 0.52 (0.49–0.55) | Open wounds of head; neck; and trunk | 5.3 |
4 | Other injuries and conditions due to external causes | 4.7 | 1.03 (0.98–1.08) | Other injuries and conditions due to external causes | 3.5 | 0.82 (0.77–0.87) | Otitis media and related conditions | 5.0 |
5 | Attention-deficit, conduct, and disruptive behavior disordersa | 4.0 | 9.71 (8.80–10.72) | Sprains and strains | 3.3 | 0.60 (0.57–0.63) | Other injuries and conditions due to external causes | 4.5 |
6 | Open wounds of head; neck; and trunk | 3.8 | 0.67 (0.64–0.70) | Abdominal pain | 3.0 | 0.76 (0.72–0.80) | Asthma | 3.6 |
7 | Otitis media and related conditions | 3.5 | 0.79 (0.75–0.83) | Open wounds of head; neck; and trunk | 2.8 | 0.68 (0.65–0.72) | Fracture of upper limb | 3.6 |
8 | Other gastrointestinal disorders | 3.4 | 1.81 (1.70–1.91) | Asthma | 2.8 | 0.75 (0.71–0.79) | Sprains and strains | 3.6 |
9 | Nausea and vomiting | 3.1 | 1.26 (1.19–1.33) | Open wounds of extremities | 2.7 | 0.73 (0.69–0.77) | Abdominal pain | 3.5 |
10 | Asthma | 2.8 | 0.68 (0.64–0.72) | Fracture of upper limb | 2.3 | 0.52 (0.49–0.55) | Fever of unknown origin | 3.2 |
. | Autism (n = 156 381) . | ADHD (n = 482 358) . | Random Sample (n = 597 777) . | |||||
---|---|---|---|---|---|---|---|---|
Rank . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . |
1 | Other upper respiratory infections | 7.7 | 0.65 (0.62–0.68) | Mood disordersa | 6.6 | 18.30 (16.55–20.24) | Other upper respiratory infections | 12.1 |
2 | Epilepsy; convulsions | 6.3 | 8.27 (7.71–8.87) | Superficial injury; contusion | 6.0 | 0.76 (0.73–0.80) | Superficial injury; contusion | 6.7 |
3 | Superficial injury; contusion | 5.0 | 0.71 (0.68–0.74) | Other upper respiratory infections | 5.8 | 0.52 (0.49–0.55) | Open wounds of head; neck; and trunk | 5.3 |
4 | Other injuries and conditions due to external causes | 4.7 | 1.03 (0.98–1.08) | Other injuries and conditions due to external causes | 3.5 | 0.82 (0.77–0.87) | Otitis media and related conditions | 5.0 |
5 | Attention-deficit, conduct, and disruptive behavior disordersa | 4.0 | 9.71 (8.80–10.72) | Sprains and strains | 3.3 | 0.60 (0.57–0.63) | Other injuries and conditions due to external causes | 4.5 |
6 | Open wounds of head; neck; and trunk | 3.8 | 0.67 (0.64–0.70) | Abdominal pain | 3.0 | 0.76 (0.72–0.80) | Asthma | 3.6 |
7 | Otitis media and related conditions | 3.5 | 0.79 (0.75–0.83) | Open wounds of head; neck; and trunk | 2.8 | 0.68 (0.65–0.72) | Fracture of upper limb | 3.6 |
8 | Other gastrointestinal disorders | 3.4 | 1.81 (1.70–1.91) | Asthma | 2.8 | 0.75 (0.71–0.79) | Sprains and strains | 3.6 |
9 | Nausea and vomiting | 3.1 | 1.26 (1.19–1.33) | Open wounds of extremities | 2.7 | 0.73 (0.69–0.77) | Abdominal pain | 3.5 |
10 | Asthma | 2.8 | 0.68 (0.64–0.72) | Fracture of upper limb | 2.3 | 0.52 (0.49–0.55) | Fever of unknown origin | 3.2 |
Source: Authors’ calculations from NEDS data 2008 to 2017. Diagnoses are from CCS. Only top 10 most frequent diagnoses listed for each group. For percent of visits column, P values for χ2 tests between the diagnostic group and the random sample was <.01 for all variables. Logistic regressions control for age (in integers), sex, hospital region, primary payer, residence, and income category. ASD, autism spectrum disorder; ADHD, attention deficit-hyperactivity disorder; OR, odds ratio; 95% CI, 95% confidence interval.
Indicates mental health diagnosis.
Most Frequent Reasons for ED Visits, % of Visits, and Odds Ratios by Age (13–18) and Diagnostic Group
. | Autism (N =80 773) . | ADHD (N = 503 074) . | Random Sample (N = 402 223) . | |||||
---|---|---|---|---|---|---|---|---|
Rank . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . |
1 | Mood disordersa | 10.2 | 5.15 (4.74–5.60) | Mood disordersa | 15.4 | 8.47 (7.95–9.02) | Sprains and strains | 8.3 |
2 | Epilepsy; convulsions | 8.8 | 12.13 (11.13–13.23) | Superficial injury; contusion | 5.4 | 0.71 (0.68–0.74) | Superficial injury; contusion | 7.0 |
3 | Attention-deficit, conduct, and disruptive behavior disordersa | 6.7 | 12.06 (10.80–13.46) | Sprains and strains | 4.6 | 0.50 (0.47–0.52) | Other upper respiratory infections | 5.9 |
4 | Superficial injury; contusion | 3.6 | 0.45 (0.42–0.48) | Anxiety disordersa | 3.0 | 3.22 (3.03–3.44) | Abdominal pain | 5.2 |
5 | Anxiety disordersa | 3.2 | 3.45 (3.15–3.79) | Suicide and intentional self-inflicted injury | 3.0 | 5.01 (4.64–5.40) | Other injuries and conditions due to external causes | 3.7 |
6 | Other injuries and conditions due to external causes | 3.0 | 0.66 (0.61–0.72) | Other upper respiratory infections | 2.8 | 0.45 (0.42–0.48) | Open wounds of extremities | 3.4 |
7 | Other upper respiratory infections | 2.6 | 0.47 (0.43–0.51) | Other injuries and conditions due to external causes | 2.8 | 0.69 (0.64–0.74) | Fracture of upper limb | 2.8 |
8 | Suicide and intentional self-inflicted injurya | 2.2 | 3.17 (2.86–3.51) | Abdominal pain | 2.7 | 0.59 (0.55–0.63) | Urinary tract infections | 2.5 |
9 | Sprains and strains | 2.2 | 0.22 (0.20–0.24) | Open wounds of extremities | 2.7 | 0.70 (0.66–0.73) | Headache; including migraine | 2.5 |
10 | Abdominal pain | 2.1 | 0.51 (0.46–0.56) | Fracture of upper limb | 1.9 | 0.52 (0.49–0.55) | Skin and subcutaneous tissue infections | 2.3 |
. | Autism (N =80 773) . | ADHD (N = 503 074) . | Random Sample (N = 402 223) . | |||||
---|---|---|---|---|---|---|---|---|
Rank . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . | OR (95% CI) . | Description . | Percent of Visits . |
1 | Mood disordersa | 10.2 | 5.15 (4.74–5.60) | Mood disordersa | 15.4 | 8.47 (7.95–9.02) | Sprains and strains | 8.3 |
2 | Epilepsy; convulsions | 8.8 | 12.13 (11.13–13.23) | Superficial injury; contusion | 5.4 | 0.71 (0.68–0.74) | Superficial injury; contusion | 7.0 |
3 | Attention-deficit, conduct, and disruptive behavior disordersa | 6.7 | 12.06 (10.80–13.46) | Sprains and strains | 4.6 | 0.50 (0.47–0.52) | Other upper respiratory infections | 5.9 |
4 | Superficial injury; contusion | 3.6 | 0.45 (0.42–0.48) | Anxiety disordersa | 3.0 | 3.22 (3.03–3.44) | Abdominal pain | 5.2 |
5 | Anxiety disordersa | 3.2 | 3.45 (3.15–3.79) | Suicide and intentional self-inflicted injury | 3.0 | 5.01 (4.64–5.40) | Other injuries and conditions due to external causes | 3.7 |
6 | Other injuries and conditions due to external causes | 3.0 | 0.66 (0.61–0.72) | Other upper respiratory infections | 2.8 | 0.45 (0.42–0.48) | Open wounds of extremities | 3.4 |
7 | Other upper respiratory infections | 2.6 | 0.47 (0.43–0.51) | Other injuries and conditions due to external causes | 2.8 | 0.69 (0.64–0.74) | Fracture of upper limb | 2.8 |
8 | Suicide and intentional self-inflicted injurya | 2.2 | 3.17 (2.86–3.51) | Abdominal pain | 2.7 | 0.59 (0.55–0.63) | Urinary tract infections | 2.5 |
9 | Sprains and strains | 2.2 | 0.22 (0.20–0.24) | Open wounds of extremities | 2.7 | 0.70 (0.66–0.73) | Headache; including migraine | 2.5 |
10 | Abdominal pain | 2.1 | 0.51 (0.46–0.56) | Fracture of upper limb | 1.9 | 0.52 (0.49–0.55) | Skin and subcutaneous tissue infections | 2.3 |
Source: Authors’ calculations from NEDS data 2008 to 2017. Diagnoses are from Clinical Classification Software (CCS). Only top 10 most frequent diagnoses listed for each group. For percent of visits column, P values for χ2 tests between the diagnostic group and the random sample was <.01 for all variables.
Logistic regressions control for age (in integers), sex, hospital region, primary payer, residence, and income category. ASD, autism spectrum disorder; ADHD, attention deficit-hyperactivity disorder; OR, odds ratio; 95% CI, 95% confidence interval.
Indicates mental health diagnosis.
Psychiatric Conditions
Psychiatric diagnoses were not among the 20 most frequently diagnosed conditions in the random sample of children, except for mood disorders for older children (ranking 12th). In contrast, psychiatric conditions were among the top 10 conditions for both younger and older children with an autism or ADHD diagnosis. These included mood disorders and suicide or intentional self-harm.
Odds Ratios
In adjusted regressions, both younger and older autistic children had higher odds of going to the ED for epilepsy and seizures compared with the random sample (OR = 8.27 [7.71–8.87] and OR = 12.13 [11.13–13.23], respectively [Tables 2 and 3 and Fig 1]). Younger autistic children had higher odds of presenting to the ED for gastrointestinal disorders (OR = 1.81 [1.70–1.91]).
Odds ratios and confidence intervals, regressions of reasons for presentation at the ED on neurodevelopmental group and individual characteristics. Odds ratios are represented by circles and 95% confidence intervals appear as bars on either side. Logistic regressions control for age (in integers), sex, hospital region, primary payer, residence, and income category. Conditions are shown in the figure only if they were ranked in the top 10 conditions in terms of frequency for either group.
Odds ratios and confidence intervals, regressions of reasons for presentation at the ED on neurodevelopmental group and individual characteristics. Odds ratios are represented by circles and 95% confidence intervals appear as bars on either side. Logistic regressions control for age (in integers), sex, hospital region, primary payer, residence, and income category. Conditions are shown in the figure only if they were ranked in the top 10 conditions in terms of frequency for either group.
Both younger and older children with ADHD had substantially higher odds of mood disorder compared with the random sample (OR = 18.30 [16.55–20.24], OR = 8.47 [7.95–9.02], respectively). Among older children with ADHD, odds of presenting to the ED for anxiety disorder or suicide or intentional self-harm were higher (OR = 3.22 [3.03–3.44]; OR = 5.01 [4.64–5.40], respectively). For younger autistic children, odds of ADHD were higher (OR = 9.71 [8.80–10.72]), and for older autistic children, odds were higher for mood disorders (OR = 5.15 [4.74–5.60]), ADHD (OR = 12.06 [10.80–13.46]), anxiety (OR = 3.45 [3.15–3.79]), and suicide or intentional self-harm (OR = 3.17 [2.86–3.51]).
Discussion
The top 10 physical health conditions prompting visits to the ED among autistic children that were not as common among the random sample were epilepsy and seizures, nausea and vomiting, and other gastrointestinal disorders. Clinicians should be prepared to treat these conditions commonly occurring among children with an autism diagnosis.
In place of physical conditions driving most visits in the random sample, mental health conditions emerged among children with diagnoses of autism or ADHD. Children with these developmental disabilities presented more often for mood disorders (10.2% for older autistic children, 15.4% for older children with ADHD). Even among younger children with ADHD, mood disorders drove a substantial portion of visits (6.6%). These findings persisted in adjusted regressions and aligned with previous evidence that mood disorders are a common reason for ED visits among autistic adolescents.
Importantly, suicide or intentional self-harm was among the top 10 reasons for ED presentation among older children with ADHD or autism diagnoses, prompting 3.0% and 2.2% of visits, respectively. These findings bolster previous evidence of increases in this diagnosis at the ED,8–11 although this trend was not necessarily apparent a decade ago.7
The increasing frequency of visits for psychiatric reasons over the last decade for children with ADHD or autism diagnoses also bolsters previous findings.8,12 Such increases could be due to a higher prevalence of psychiatric conditions, increasing awareness of psychiatric conditions, lack of adequate care outside the ED environment, or other reasons. Children with these developmental conditions had higher rates of admission to inpatient care and transfer to other services. Together, these findings could indicate an increasing prevalence of more severe psychiatric impairments over time, although additional research is warranted.
Overall, findings underline the importance of identifying psychiatric issues, arranging for continuing care, and screening ED visits for potential self-harm. Early identification of suicidal ideation may prevent self-harm; ED screening with evidence-based questionnaires is feasible in a pediatric population and could identify cases that would otherwise be missed.13 In addition to routine screening for abuse, clinicians should screen for self-harm risk and facilitate the continuation of care with psychiatric services when appropriate. Referral, persistent follow-up, and warm transfers could ensure patients obtain necessary psychiatric care.14,15
This study has some limitations. NEDS data are at the encounter level, obviating longitudinal investigation and assessment of repeat visits. Second, diagnostic practices changed over this period, so cases captured may differ over time. However, extreme discontinuity is not likely, as diagnoses at ED visits may not rely on extensive clinical testing. Third, there are co-occurring diagnoses, so some visits reflect children with both autism and ADHD diagnoses. We allowed for this overlap to capture cases in which children with 1 developmental condition presented to the ED for the other developmental condition. Therefore, findings should be considered for the 2 groups independently, compared only with the random sample. Fourth, groupings were based on coding designed for billing purposes; thus, there may be coding variation among providers. Lastly, we may miss individuals with undiagnosed psychiatric conditions, which could lead to underestimation of differences. We note that NEDS data are nationally representative of ED visits in the United States from 2008 to 2017, representing individuals regardless of insurance coverage.
It is important for clinicians to understand common reasons for presentation to the ED among autistic children and children with ADHD to respond effectively and sensitively. ED visits may be an important point of contact to assess the risk of self-injurious behavior and facilitate psychiatric evaluation and/or continuing care.
Acknowledgments
We thank Anne Roux and Jessica Rast, AJ Drexel Autism Institute, Zachary Williams, Vanderbilt University, and Emily Hotez, University of California, Los Angeles for thoughtful comments on the manuscript. We greatly appreciate data visualization assistance from Kate Verstreate at the AJ Drexel Autism Institute.
Dr Schott conceptualized the study, conducted literature review, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Shea conceptualized the study and reviewed and revised the manuscript; Mr Tao conducted all data analysis and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: This study was supported by NIH grant 5R01MH117653-02. This project was also supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under UJ2MC31073, Maternal and Child Health-Autism Transitions Research Project and UT2MC39440, Autism Intervention Research Network on Physical Health. The content and conclusions presented are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the HRSA, the US Department of Health and Human Services, or the US Government. The NIH and HRSA had no role in the design or conduct of this study. Funded by the National Institutes of Health (NIH).
- ADHD
attention-deficit/hyperactivity disorder
- ASD
autism spectrum disorder
- CCS
Clinical Classification Software
- ED
emergency department
- ICD-9
International Classification of Diseases, 9th Revision
- ICD-10
International Classification of Diseases, 10th Revision
- NEDS
Nationwide Emergency Department Sample
- OR
odds ratio
References
Competing Interests
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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