Autism Spectrum Disorder and Maltreatment in Children Treated in US Emergency Departments, 2020-2021

Margaret Kyle, BA
Ashley Blanchard, MD
Matthew Russell, MPH
Caleb Ing, MD
Carolyn DiGuiseppi, MD, MPH, PhD
Guohua Li, MD, DrPH

Children with autism spectrum disorder (ASD) are at increased risk of unintentional and intentional injury. A significant cause of injury in children is maltreatment, which is more common in children with disabilities, but there is limited data on maltreatment in children with ASD. This study sought to identify epidemiological factors associated with maltreatment in children with ASD aged 1-20 years using a national dataset of emergency department (ED) visits.

We utilized the National Emergency Department Sample (NEDS) data created by the Healthcare Cost and Utilization Project (HCUP). We included ED visits by children aged 1-20 years documented in NEDS from 2020-2021 and used ICD-10 codes to identify diagnosis of ASD (F84.0), suspected (T76.0-T76.9) and confirmed maltreatment (T74.0-T74.9), attention-deficit/hyperactivity disorder (ADHD; F90.X), and intellectual disability (ID; F70-F79). We computed the weighted total number of ED visits and visits with a diagnosis of suspected or confirmed abuse according to ASD, ADHD, and ID diagnoses, age, sex, hospital region, hospital urbanicity, and insurance payor, generating odds ratios (ORs) and 95% confidence intervals (CIs) for maltreatment associated with each variable. Using multivariable logistic regression, we estimated ORs and 95% CIs for maltreatment associated with ASD while adjusting for these variables.

The NEDS recorded a total of 11,788,975 ED visits in children aged 1-20 years in 2020-2021, generating a weighted total of 50,184,622 visits; of them, 542,815 (1.1%) had a diagnosis of ASD and 148,083 (0.3%) had a diagnosis of suspected or confirmed maltreatment. Sexual abuse accounted for 65.6% of maltreatment cases, followed by physical abuse (21.6%), psychological abuse (3.1%), and other abuse (9.7%). ASD was associated with 76% increased odds of maltreatment (adjusted OR: 1.76 (1.54, 2.00)). Other risk factors for maltreatment were female sex (adjusted OR: 2.99 (2.76, 3.23)), ID (adjusted OR: 2.48 (2.03, 3.02)), and ADHD (adjusted OR: 2.18 (1.96, 2.43)). In analyses stratified by sex, ASD was associated with 69% increased odds of physical abuse (adjusted OR: 1.69 (1.41, 2.04)) and 74% increased odds of sexual abuse (adjusted OR: 1.74 (1.26, 2.41)) among male children, and 59% increased odds of physical abuse (adjusted OR: 1.59 (1.17, 2.16)) but 23% increased odds of sexual abuse (adjusted OR: 1.23 (0.98, 1.55)) among female children.

Children with ASD are at heightened risk of maltreatment. Their risk varies by child sex and maltreatment sub-type, and the risk increase is greatest for physical and sexual abuse in males with ASD. Increased risk of maltreatment in children with ASD warrants targeted interventions for youth with ASD and their caretakers to prevent maltreatment-related injury.

1. Children with ASD have higher odds of maltreatment. 2. Odds of maltreatment vary by sex and type of maltreatment in children with ASD. 3. The greatest increase in odds of maltreatment in children with ASD is for physical and sexual abuse in males.