Contributions to inclusive and impactful development and psychopathology science: interrogating ecology-linked vulnerability and resilience opportunities.

Since its launch in a 1984 Special Issue of Child Development, significant contributions and insights have followed that have expanded our understanding of psychopathology and normal human growth and development. Despite these efforts, there are persistent and under-analyzed skewed patterns of vulnerability across and within groups. The persistence of a motivated forgetfulness to acknowledge citizens' uneven access to resources and supports, or as stated elsewhere, "inequality presence denial," is, at minimum, a policy, social and health practice problem. This article will examine some of these issues from the standpoint of a universal human vulnerability perspective. It also investigates sources of resistance to acknowledging and responding to the scholarship production problem of uneven representations of basic human development research versus psychopathology preoccupations by race. Collectively, findings suggest interesting "patchwork" patterns of particular cultural repertoires as ordinary social and scholarly traditions.

Interrogating multisystem intended pathways to youth thriving and resilience: Benefits of inclusive human development theoretical framing.

Moving more deeply into the 21st century and acknowledging the ongoing patterned needs of children, there continues to be broadly voiced sentiments about the importance of all children's thriving, adaptive coping, and resiliency. This paper notes that social science more broadly and developmental science specifically is a major resource determinative of the nature of remedies conceptualized, designed, and implemented. Evident is that the harms experienced by children and the solutions implemented by delivery systems are frequently unaligned. Efficacy and impact do not appear to be improved by multisystem integration delivery. This paper explores the benefits of incorporating inclusive and shared human development theory. As well, it examines the need to question the character virtue of the multisystem integration efforts intended to afford supportive solutions required for youths' thriving and resiliency. Specifically, it addresses whether democratic and equity relevant character values are integrated into public and privately funded intended supportive systems. The position taken is that whether considered under conditions of trauma illustrated by the global COVID pandemic or the efficacy of systems intended to aid the most vulnerable youngsters, the character of the content of support and its delivery matter and can benefit from inclusive human development interrogation and theorizing.

The Invisibility of Power: A Cultural Ecology of Development in the Contemporary United States.

This article highlights the invisible power those in racial and gendered privilege continue to hold in the contemporary United States and the harmful psychological effects of this power on both those it oppresses and, importantly, those who wield it. A lack of empathy and an inability for compassion arise in individuals holding sociopolitical and cultural power, and we highlight how this psychological condition is qualifiable as psychosis and question why it has not been discussed as such in the literature until now. We also, however, bring attention to the invisible psychological power that marginalized populations in the United States hold, invisible because it has been left largely unrecognized by mainstream cultural forces. By centering the ways American cultural minorities successfully navigate multiply oppressive structural systems, we conclude with a reflection on how intersectional feminism can offer a philosophical lens through which to mitigate the unhealthy developmental outcomes and effects of White heteronormative male power.

Vulnerability and resiliency implications of human capital and linked inequality presence denial perspectives: Acknowledging Zigler's contributions to child well-being.

Edward Zigler's groundbreaking research on child development resulted in the historic Head Start program. It is useful to examine the theoretical implications of his work by applying a human development theoretical perspective. Phenomenological variant of ecological systems theory (PVEST) is a strengths-based theoretical framework that engages the variability of resource access and coping strategies that promote positive identity development for diverse children. While skill acquisition is a key focus of human capital theory's engagement of early childhood needs, this article highlights the on-going status of human vulnerability that undergirds identity development over the life course. The authors note that "inequality presence denial" combines with high-risk contexts, framed by geography and psychohistoric moments (e.g., The Great Recession, COVID-19), to alter diverse children's developmental pathways. The acknowledgement of "morbid risk" motivates the urgency for research that builds upon Zigler's innovations and privileges human development imperatives. The case study explores these concepts by examining the challenges and assets available to mothers in a low-income community. The article's closing notes developments in the field of economics that ameliorate human capital theory's conceptual limitations, underscoring human development's theoretical strength in motivating research and policies that are maximally responsive to children's positive identity development.

Family social capital and life satisfaction among older adults living alone in urban China: the moderating role of functional health.

Objectives: The present study examined the moderating effects of functional health on the association between family social capital and life satisfaction among older adults who live alone in urban China.Method: Data for this study were derived from a study "Survey on older adults aged 70 and above who live alone in urban China," which was carried out in five Chinese cities between November 2013 and May 2015. 2801 respondents passed the screening test of cognitive capacities and successfully completed the survey. Family social capital was operationalized as family interaction, number of children, and family relationship. Random-effects logistic regression was conducted to test the proposed hypotheses.Results: The moderating effects of functional health on the association between family interaction and life satisfaction were identified. While family interaction was positively associated with life satisfaction among older adults without disabilities who live alone, family interaction was negatively associated with life satisfaction among those with disabilities. Furthermore, the association between number of children and life satisfaction was nonsignificant among older adults without disabilities, when family relationship was controlled. However, number of children was positively associated with life satisfaction among those with disabilities. Finally, the results showed family relationship were important protective factors of life satisfaction among older adults living alone, regardless of their functional health levels.Conclusion: Theoretical aspects on how family social capital, living alone, and functional health are interwoven and influence mental health in later life were deliberated. Policy and intervention implications were discussed.

Trends and risk factors of adolescent opioid abuse/misuse: understanding the opioid epidemic among adolescents.

Over the past decade, opioid abuse/misuse has grown from a local problem into a national crisis, causing the U.S. Health and Human Services (HSS) to declare a public health emergency. The number of those dying from opioid abuse has increased, especially among adolescents. Since 2014, death rates due to opioid overdose have been highest in persons aged 15-19 years. This systematic review examines past and present research concerning opioid abuse/misuse and seeks to bring more attention to the growing opioid epidemic affecting adolescents aged 12-25 years nationwide. Keywords such as "adolescent", "opioid", "overdose", "opioid misuse", and phrases including "opioid use and race", "income status and opioids", were used to find common demographic trends which can be attributed to this population. The process of gathering and disseminating information currently available on this subject helps highlight a somewhat taboo subject involving vulnerable members of our community. It is imperative that healthcare providers, in particular, those who treat adolescents, have access to current research and resources that support efforts to combat this persistent issue. In addition, this information will prove useful to those who have the ability to change policies and how this current crisis is being managed. Results from the research indicate that opioid abuse/misuse in adolescents is rising and race, gender and income play a role in the abuse/misuse of opioids. Likewise, the research proves that more opportunities for education and access to adequate treatment are paramount to ending the prevalence of opioid abuse/misuse.

Innovating resilience promotion: Integrating cultural practices, social ecologies and development-sensitive conceptual strategies for advancing child well-being.

This chapter's goal is to interrogate the intersectional significance of race and socioeconomic status for children of varied statuses of human vulnerability. It provides a context-connected, culture acknowledging, systems model and identity formation perspective. This strategy is ideal for delineating behavioral consistencies (and interpreting inconsistencies). When operationalized with programming opportunities, it accommodates the nation's diversity and aids the interpretation of findings. This chapter is divided into several sections: First, it interrogates critical insights afforded by a "resiliency-vulnerability" approach; second, it draws attention to the roles of culture, culturally competent practices, and justice-informed contexts for children's perception-based "meaning making" as each-increasingly with age-navigates multiple social ecologies. Third, it shifts to and emphasizes the intersectionally relevant factors of race (e.g., identifiability and skin color stereotyping) and socioeconomic status (i.e., both low resourced and privileging situations); and following a synthesis of the previous sections-as Section 4-it then frames the cumulative and integrated conceptual strategy (phenomenological variant of ecological systems theory: PVEST). In Section 5, the chapter presents theory-focused exemplars to illustrate the theory's efficacy, which are followed by results of two recent preliminary application projects. Salient is that the two projects presenting preliminary findings add to and afford important child development insights salient as strategies for neutralizing intersectionality effects and maximizing resiliency outcomes. To sum, synthesizing several decades of scholarship, theorizing, contemporary research and programming application efforts, the handbook chapter concludes with suggested strategies for creating more informed policies and practices relevant to all children's overall resiliency, healthy development and well-being.

Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 4 Years - Early Autism and Developmental Disabilities Monitoring Network, Seven Sites, United States, 2010, 2012, and 2014.

PROBLEM/CONDITION: Autism spectrum disorder (ASD) is estimated to affect up to 3% of children in the United States. Public health surveillance for ASD among children aged 4 years provides information about trends in prevalence, characteristics of children with ASD, and progress made toward decreasing the age of identification of ASD so that evidence-based interventions can begin as early as possible. PERIOD COVERED: 2010, 2012, and 2014. DESCRIPTION OF SYSTEM: The Early Autism and Developmental Disabilities Monitoring (Early ADDM) Network is an active surveillance system that provides biennial estimates of the prevalence and characteristics of ASD among children aged 4 years whose parents or guardians lived within designated sites. During surveillance years 2010, 2012, or 2014, data were collected in seven sites: Arizona, Colorado, Missouri, New Jersey, North Carolina, Utah, and Wisconsin. The Early ADDM Network is a subset of the broader ADDM Network (which included 13 total sites over the same period) that has been conducting ASD surveillance among children aged 8 years since 2000. Each Early ADDM site covers a smaller geographic area than the broader ADDM Network. Early ADDM ASD surveillance is conducted in two phases using the same methods and project staff members as the ADDM Network. The first phase consists of reviewing and abstracting data from children's records, including comprehensive evaluations performed by community professionals. Sources for these evaluations include general pediatric health clinics and specialized programs for children with developmental disabilities. In addition, special education records (for children aged ≥3 years) were reviewed for Arizona, Colorado, New Jersey, North Carolina, and Utah, and early intervention records (for children aged 0 to <3 years) were reviewed for New Jersey, North Carolina, Utah, and Wisconsin; in Wisconsin, early intervention records were reviewed for 2014 only. The second phase involves a review of the abstracted evaluations by trained clinicians using a standardized case definition and method. A child is considered to meet the surveillance case definition for ASD if one or more comprehensive evaluations of that child completed by a qualified professional describes behaviors consistent with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS, including atypical autism), or Asperger disorder (2010, 2012, and 2014). For 2014 only, prevalence estimates based on surveillance case definitions according to DSM-IV-TR and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) were compared. This report provides estimates of overall ASD prevalence and prevalence by sex and race/ethnicity; characteristics of children aged 4 years with ASD, including age at first developmental evaluation, age at ASD diagnosis, and cognitive function; and trends in ASD prevalence and characteristics among Early ADDM sites with data for all 3 surveillance years (2010, 2012, and 2014), including comparisons with children aged 8 years living in the same geographic area. Analyses of time trends in ASD prevalence are restricted to the three sites that contributed data for all 3 surveillance years with consistent data sources (Arizona, Missouri, and New Jersey). RESULTS: The overall ASD prevalence was 13.4 per 1,000 children aged 4 years in 2010, 15.3 in 2012, and 17.0 in 2014 for Early ADDM sites with data for the specific years. ASD prevalence was determined using a surveillance case definition based on DSM-IV-TR. Within each surveillance year, ASD prevalence among children aged 4 years varied across surveillance sites and was lowest each year for Missouri (8.5, 8.1, and 9.6 per 1,000, for 2010, 2012, and 2014, respectively) and highest each year for New Jersey (19.7, 22.1, and 28.4 per 1,000, for the same years, respectively). Aggregated prevalence estimates were higher for sites that reviewed education and health care records than for sites that reviewed only health care records. Among all participating sites and years, ASD prevalence among children aged 4 years was consistently higher among boys than girls; prevalence ratios ranged from 2.6 (Arizona and Wisconsin in 2010) to 5.2 boys per one girl (Colorado in 2014). In 2010, ASD prevalence was higher among non-Hispanic white children than among Hispanic children in Arizona and non-Hispanic black children in Missouri; no other differences were observed by race/ethnicity. Among four sites with ≥60% data on cognitive test scores (Arizona, New Jersey, North Carolina, and Utah), the frequency of co-occurring intellectual disabilities was significantly higher among children aged 4 years than among those aged 8 years for each site in each surveillance year except Arizona in 2010. The percentage of children with ASD who had a first evaluation by age 36 months ranged from 48.8% in Missouri in 2012 to 88.9% in Wisconsin in 2014. The percentage of children with a previous ASD diagnosis from a community provider varied by site, ranging from 43.0% for Arizona in 2012 to 86.5% for Missouri in 2012. The median age at earliest known ASD diagnosis varied from 28 months in North Carolina in 2014 to 39.0 months in Missouri and Wisconsin in 2012. In 2014, the ASD prevalence based on the DSM-IV-TR case definition was 20% higher than the prevalence based on the DSM-5 (17.0 versus 14.1 per 1,000, respectively). Trends in ASD prevalence and characteristics among children aged 4 years during the study period were assessed for the three sites with data for all 3 years and consistent data sources (Arizona, Missouri, and New Jersey) using the DSM-IV-TR case definition; prevalence was higher in 2014 than in 2010 among children aged 4 years in New Jersey and was stable in Arizona and Missouri. In Missouri, ASD prevalence was higher among children aged 8 years than among children aged 4 years. The percentage of children with ASD who had a comprehensive evaluation by age 36 months was stable in Arizona and Missouri and decreased in New Jersey. In the three sites, no change occurred in the age at earliest known ASD diagnosis during 2010-2014. INTERPRETATION: The findings suggest that ASD prevalence among children aged 4 years was higher in 2014 than in 2010 in one site and remained stable in others. Among children with ASD, the frequency of cognitive impairment was higher among children aged 4 years than among those aged 8 years and suggests that surveillance at age 4 years might more often include children with more severe symptoms or those with co-occurring conditions such as intellectual disability. In the sites with data for all years and consistent data sources, no change in the age at earliest known ASD diagnosis was found, and children received their first developmental evaluation at the same or a later age in 2014 compared with 2010. Delays in the initiation of a first developmental evaluation might adversely affect children by delaying access to treatment and special services that can improve outcomes for children with ASD. PUBLIC HEALTH ACTION: Efforts to increase awareness of ASD and improve the identification of ASD by community providers can facilitate early diagnosis of children with ASD. Heterogeneity of results across sites suggests that community-level differences in evaluation and diagnostic services as well as access to data sources might affect estimates of ASD prevalence and age of identification. Continuing improvements in providing developmental evaluations to children as soon as developmental concerns are identified might result in earlier ASD diagnoses and earlier receipt of services, which might improve developmental outcomes.

Automated Extraction of Diagnostic Criteria From Electronic Health Records for Autism Spectrum Disorders: Development, Evaluation, and Application.

BACKGROUND: Electronic health records (EHRs) bring many opportunities for information utilization. One such use is the surveillance conducted by the Centers for Disease Control and Prevention to track cases of autism spectrum disorder (ASD). This process currently comprises manual collection and review of EHRs of 4- and 8-year old children in 11 US states for the presence of ASD criteria. The work is time-consuming and expensive. OBJECTIVE: Our objective was to automatically extract from EHRs the description of behaviors noted by the clinicians in evidence of the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Previously, we reported on the classification of entire EHRs as ASD or not. In this work, we focus on the extraction of individual expressions of the different ASD criteria in the text. We intend to facilitate large-scale surveillance efforts for ASD and support analysis of changes over time as well as enable integration with other relevant data. METHODS: We developed a natural language processing (NLP) parser to extract expressions of 12 DSM criteria using 104 patterns and 92 lexicons (1787 terms). The parser is rule-based to enable precise extraction of the entities from the text. The entities themselves are encompassed in the EHRs as very diverse expressions of the diagnostic criteria written by different people at different times (clinicians, speech pathologists, among others). Due to the sparsity of the data, a rule-based approach is best suited until larger datasets can be generated for machine learning algorithms. RESULTS: We evaluated our rule-based parser and compared it with a machine learning baseline (decision tree). Using a test set of 6636 sentences (50 EHRs), we found that our parser achieved 76% precision, 43% recall (ie, sensitivity), and >99% specificity for criterion extraction. The performance was better for the rule-based approach than for the machine learning baseline (60% precision and 30% recall). For some individual criteria, precision was as high as 97% and recall 57%. Since precision was very high, we were assured that criteria were rarely assigned incorrectly, and our numbers presented a lower bound of their presence in EHRs. We then conducted a case study and parsed 4480 new EHRs covering 10 years of surveillance records from the Arizona Developmental Disabilities Surveillance Program. The social criteria (A1 criteria) showed the biggest change over the years. The communication criteria (A2 criteria) did not distinguish the ASD from the non-ASD records. Among behaviors and interests criteria (A3 criteria), 1 (A3b) was present with much greater frequency in the ASD than in the non-ASD EHRs. CONCLUSIONS: Our results demonstrate that NLP can support large-scale analysis useful for ASD surveillance and research. In the future, we intend to facilitate detailed analysis and integration of national datasets.

Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012.

PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2012. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance system that provides estimates of the prevalence and characteristics of ASD among children aged 8 years whose parents or guardians reside in 11 ADDM Network sites in the United States (Arkansas, Arizona, Colorado, Georgia, Maryland, Missouri, New Jersey, North Carolina, South Carolina, Utah, and Wisconsin). Surveillance to determine ASD case status is conducted in two phases. The first phase consists of screening and abstracting comprehensive evaluations performed by professional service providers in the community. Data sources identified for record review are categorized as either 1) education source type, including developmental evaluations to determine eligibility for special education services or 2) health care source type, including diagnostic and developmental evaluations. The second phase involves the review of all abstracted evaluations by trained clinicians to determine ASD surveillance case status. A child meets the surveillance case definition for ASD if one or more comprehensive evaluations of that child completed by a qualified professional describes behaviors that are consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder-not otherwise specified (including atypical autism), or Asperger disorder. This report provides ASD prevalence estimates for children aged 8 years living in catchment areas of the ADDM Network sites in 2012, overall and stratified by sex, race/ethnicity, and the type of source records (education and health records versus health records only). In addition, this report describes the proportion of children with ASD with a score consistent with intellectual disability on a standardized intellectual ability test, the age at which the earliest known comprehensive evaluation was performed, the proportion of children with a previous ASD diagnosis, the specific type of ASD diagnosis, and any special education eligibility classification. RESULTS: For 2012, the combined estimated prevalence of ASD among the 11 ADDM Network sites was 14.5 per 1,000 (one in 69) children aged 8 years. Estimated prevalence was significantly higher among boys aged 8 years (23.4 per 1,000) than among girls aged 8 years (5.2 per 1,000). Estimated ASD prevalence was significantly higher among non-Hispanic white children aged 8 years (15.3 per 1,000) compared with non-Hispanic black children (13.1 per 1,000), and Hispanic (10.2 per 1,000) children aged 8 years. Estimated prevalence varied widely among the 11 ADDM Network sites, ranging from 8.2 per 1,000 children aged 8 years (in the area of the Maryland site where only health care records were reviewed) to 24.6 per 1,000 children aged 8 years (in New Jersey, where both education and health care records were reviewed). Estimated prevalence was higher in surveillance sites where education records and health records were reviewed compared with sites where health records only were reviewed (17.1 per 1,000 and 10.4 per 1,000 children aged 8 years, respectively; p<0.05). Among children identified with ASD by the ADDM Network, 82% had a previous ASD diagnosis or educational classification; this did not vary by sex or between non-Hispanic white and non-Hispanic black children. A lower percentage of Hispanic children (78%) had a previous ASD diagnosis or classification compared with non-Hispanic white children (82%) and with non-Hispanic black children (84%). The median age at earliest known comprehensive evaluation was 40 months, and 43% of children had received an earliest known comprehensive evaluation by age 36 months. The percentage of children with an earliest known comprehensive evaluation by age 36 months was similar for boys and girls, but was higher for non-Hispanic white children (45%) compared with non-Hispanic black children (40%) and Hispanic children (39%). INTERPRETATION: Overall estimated ASD prevalence was 14.5 per 1,000 children aged 8 years in the ADDM Network sites in 2012. The higher estimated prevalence among sites that reviewed both education and health records suggests the role of special education systems in providing comprehensive evaluations and services to children with developmental disabilities. Disparities by race/ethnicity in estimated ASD prevalence, particularly for Hispanic children, as well as disparities in the age of earliest comprehensive evaluation and presence of a previous ASD diagnosis or classification, suggest that access to treatment and services might be lacking or delayed for some children. PUBLIC HEALTH ACTION: The ADDM Network will continue to monitor the prevalence and characteristics of ASD among children aged 8 years living in selected sites across the United States. Recommendations from the ADDM Network include enhancing strategies to 1) lower the age of first evaluation of ASD by community providers in accordance with the Healthy People 2020 goal that children with ASD are evaluated by age 36 months and begin receiving community-based support and services by age 48 months; 2) reduce disparities by race/ethnicity in identified ASD prevalence, the age of first comprehensive evaluation, and presence of a previous ASD diagnosis or classification; and 3) assess the effect on ASD prevalence of the revised ASD diagnostic criteria published in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Opportunities and Challenges for Dietary Arsenic Intervention.

The diet is emerging as the dominant source of arsenic exposure for most of the U.S. population. Despite this, limited regulatory efforts have been aimed at mitigating exposure, and the role of diet in arsenic exposure and disease processes remains understudied. In this brief, we discuss the evidence linking dietary arsenic intake to human disease and discuss challenges associated with exposure characterization and efforts to quantify risks. In light of these challenges, and in recognition of the potential longer-term process of establishing regulation, we introduce a framework for shorter-term interventions that employs a field-to-plate food supply chain model to identify monitoring, intervention, and communication opportunities as part of a multisector, multiagency, science-informed, public health systems approach to mitigation of dietary arsenic exposure. Such an approach is dependent on coordination across commodity producers, the food industry, nongovernmental organizations, health professionals, researchers, and the regulatory community. https://doi.org/10.1289/EHP3997.

Phenomenology and Intersectionality: Using PVEST as a Frame for Adolescent Identity Formation Amid Intersecting Ecological Systems of Inequality.

Beginning with Erikson, identity formation has often been framed as a salient developmental challenge for adolescents. Recent theoretical advances situate this identity formation as a central life course process involving ecological and social context associated with diverse experiences and characteristics. Some scholars have employed intersectionality as a call to study experiences of individuals who belong to multiple marginalized groups. In this article, we argue that developmental research would be served by a return to Crenshaw's formulation of intersectionality-that is, that marginalization involves systematic inequality and interlocking systems of oppression-as integrated with Spencer's phenomenological variant of ecological systems theory (PVEST). The latter was formulated as a needed critique of traditional developmental theories that generally ignored the problem of inequality as experienced through multiple layers of navigated contexts. Problematic ecological contexts can be understood through intersectionality's forefronting of complex structures and social positionality-that power dynamics and interconnected systems lead to differential outcomes within socially constructed categories like class, race, and gender. PVEST complements these insights through an attentiveness to phenomenological interpretations and responses-the "how" and "why" of the process. Therefore, we argue that adolescent outcomes should be understood both from the top and the bottom, including how youth interpret and cope with their vulnerability, based upon experiences of interlocking systems of oppression. The consequent synthesis should bolster the identification of pillar-like supports needed by youth and which afford effective assistance across respective socialization contexts.

Strategy for 90% autoverification of clinical chemistry and immunoassay test results using six sigma process improvement.

Six Sigma involves a structured process improvement strategy that places processes on a pathway to continued improvement. The data presented here summarizes a project that took three clinical laboratories from autoverification processes that allowed between about 40% to 60% of tests being auto-verified to more than 90% of tests and samples auto-verified. The project schedule, metrics and targets, a description of the previous system and detailed information on the changes made to achieve greater than 90% auto-verification is presented for this Six Sigma DMAIC (Design, Measure, Analyze, Improve, Control) process improvement project.

Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014.

PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2014. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance system that provides estimates of the prevalence of autism spectrum disorder (ASD) among children aged 8 years whose parents or guardians reside within 11 ADDM sites in the United States (Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin). ADDM surveillance is conducted in two phases. The first phase involves review and abstraction of comprehensive evaluations that were completed by professional service providers in the community. Staff completing record review and abstraction receive extensive training and supervision and are evaluated according to strict reliability standards to certify effective initial training, identify ongoing training needs, and ensure adherence to the prescribed methodology. Record review and abstraction occurs in a variety of data sources ranging from general pediatric health clinics to specialized programs serving children with developmental disabilities. In addition, most of the ADDM sites also review records for children who have received special education services in public schools. In the second phase of the study, all abstracted information is reviewed systematically by experienced clinicians to determine ASD case status. A child is considered to meet the surveillance case definition for ASD if he or she displays behaviors, as described on one or more comprehensive evaluations completed by community-based professional providers, consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for autistic disorder; pervasive developmental disorder-not otherwise specified (PDD-NOS, including atypical autism); or Asperger disorder. This report provides updated ASD prevalence estimates for children aged 8 years during the 2014 surveillance year, on the basis of DSM-IV-TR criteria, and describes characteristics of the population of children with ASD. In 2013, the American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which made considerable changes to ASD diagnostic criteria. The change in ASD diagnostic criteria might influence ADDM ASD prevalence estimates; therefore, most (85%) of the records used to determine prevalence estimates based on DSM-IV-TR criteria underwent additional review under a newly operationalized surveillance case definition for ASD consistent with the DSM-5 diagnostic criteria. Children meeting this new surveillance case definition could qualify on the basis of one or both of the following criteria, as documented in abstracted comprehensive evaluations: 1) behaviors consistent with the DSM-5 diagnostic features; and/or 2) an ASD diagnosis, whether based on DSM-IV-TR or DSM-5 diagnostic criteria. Stratified comparisons of the number of children meeting either of these two case definitions also are reported. RESULTS: For 2014, the overall prevalence of ASD among the 11 ADDM sites was 16.8 per 1,000 (one in 59) children aged 8 years. Overall ASD prevalence estimates varied among sites, from 13.1-29.3 per 1,000 children aged 8 years. ASD prevalence estimates also varied by sex and race/ethnicity. Males were four times more likely than females to be identified with ASD. Prevalence estimates were higher for non-Hispanic white (henceforth, white) children compared with non-Hispanic black (henceforth, black) children, and both groups were more likely to be identified with ASD compared with Hispanic children. Among the nine sites with sufficient data on intellectual ability, 31% of children with ASD were classified in the range of intellectual disability (intelligence quotient [IQ] <70), 25% were in the borderline range (IQ 71-85), and 44% had IQ scores in the average to above average range (i.e., IQ >85). The distribution of intellectual ability varied by sex and race/ethnicity. Although mention of developmental concerns by age 36 months was documented for 85% of children with ASD, only 42% had a comprehensive evaluation on record by age 36 months. The median age of earliest known ASD diagnosis was 52 months and did not differ significantly by sex or race/ethnicity. For the targeted comparison of DSM-IV-TR and DSM-5 results, the number and characteristics of children meeting the newly operationalized DSM-5 case definition for ASD were similar to those meeting the DSM-IV-TR case definition, with DSM-IV-TR case counts exceeding DSM-5 counts by less than 5% and approximately 86% overlap between the two case definitions (kappa = 0.85). INTERPRETATION: Findings from the ADDM Network, on the basis of 2014 data reported from 11 sites, provide updated population-based estimates of the prevalence of ASD among children aged 8 years in multiple communities in the United States. The overall ASD prevalence estimate of 16.8 per 1,000 children aged 8 years in 2014 is higher than previously reported estimates from the ADDM Network. Because the ADDM sites do not provide a representative sample of the entire United States, the combined prevalence estimates presented in this report cannot be generalized to all children aged 8 years in the United States. Consistent with reports from previous ADDM surveillance years, findings from 2014 were marked by variation in ASD prevalence when stratified by geographic area, sex, and level of intellectual ability. Differences in prevalence estimates between black and white children have diminished in most sites, but remained notable for Hispanic children. For 2014, results from application of the DSM-IV-TR and DSM-5 case definitions were similar, overall and when stratified by sex, race/ethnicity, DSM-IV-TR diagnostic subtype, or level of intellectual ability. PUBLIC HEALTH ACTION: Beginning with surveillance year 2016, the DSM-5 case definition will serve as the basis for ADDM estimates of ASD prevalence in future surveillance reports. Although the DSM-IV-TR case definition will eventually be phased out, it will be applied in a limited geographic area to offer additional data for comparison. Future analyses will examine trends in the continued use of DSM-IV-TR diagnoses, such as autistic disorder, PDD-NOS, and Asperger disorder in health and education records, documentation of symptoms consistent with DSM-5 terminology, and how these trends might influence estimates of ASD prevalence over time. The latest findings from the ADDM Network provide evidence that the prevalence of ASD is higher than previously reported estimates and continues to vary among certain racial/ethnic groups and communities. With prevalence of ASD ranging from 13.1 to 29.3 per 1,000 children aged 8 years in different communities throughout the United States, the need for behavioral, educational, residential, and occupational services remains high, as does the need for increased research on both genetic and nongenetic risk factors for ASD.

Autoverification process improvement by Six Sigma approach: Clinical chemistry & immunoassay.

OBJECTIVE: This study examines effectiveness of a project to enhance an autoverification (AV) system through application of Six Sigma (DMAIC) process improvement strategies. DESIGN AND METHODS: Similar AV systems set up at three sites underwent examination and modification to produce improved systems while monitoring proportions of samples autoverified, the time required for manual review and verification, sample processing time, and examining characteristics of tests not autoverified. This information was used to identify areas for improvement and monitor the impact of changes. RESULTS: Use of reference range based criteria had the greatest impact on the proportion of tests autoverified. To improve AV process, reference range based criteria was replaced with extreme value limits based on a 99.5% test result interval, delta check criteria were broadened, and new specimen consistency rules were implemented. Decision guidance tools were also developed to assist staff using the AV system. The mean proportion of tests and samples autoverified improved from <62% for samples and <80% for tests, to >90% for samples and >95% for tests across all three sites. The new AV system significantly decreased turn-around time and total sample review time (to about a third), however, time spent for manual review of held samples almost tripled. There was no evidence of compromise to the quality of testing process and <1% of samples held for exceeding delta check or extreme limits required corrective action. CONCLUSIONS: The Six Sigma (DMAIC) process improvement methodology was successfully applied to AV systems resulting in an increase in overall test and sample AV by >90%, improved turn-around time, reduced time for manual verification, and with no obvious compromise to quality or error detection.

Characterizing Health Disparities in the Age of Autism Diagnosis in a Study of 8-Year-Old Children.

The diagnosis of autism spectrum disorder (ASD) is often delayed from the time of noted concerns to the actual diagnosis. The current study used child- and family-level factors to identify homogeneous classes in a surveillance-based sample (n = 2303) of 8-year-old children with ASD. Using latent class analysis, a 5-class model emerged and the class memberships were examined in relation to the child's median age at ASD diagnosis. Class 3, with known language delays and a high advantage socioeconomically had the lowest age of ASD diagnosis (46.74 months) in comparison to Classes 1 (64.99 months), 4 (58.14 months), and 5 (69.78 months) in this sample. Findings demonstrate sociodemographic and developmental disparities related to the age at ASD diagnosis.

Optimizing Corpus Creation for Training Word Embedding in Low Resource Domains: A Case Study in Autism Spectrum Disorder (ASD).

Automating the extraction of behavioral criteria indicative of Autism Spectrum Disorder (ASD) in electronic health records (EHRs) can contribute significantly to the effort to monitor the condition. Word embedding algorithms such as Word2Vec can encode semantic meanings of words in vectors and assist in automated vocabulary discovery from EHRs. However, text available for training word embeddings for ASD is miniscule compared to the billions of tokens typically used. We evaluate the importance of corpus specificity versus size and hypothesize that for specific domains small corpora can generate excellent word embeddings. We custom-built 6 ASD-themed corpora (N=4482), using ASD EHRs and abstracts from PubMed (N=39K) and PsychInfo (N=69K) and evaluated them. We were able to generate the most useful 200-dimension embeddings based on the small ASD EHR data. Due to diversity in its vocabulary, the abstract-based embeddings generated fewer related terms and saw minimal improvement when the size of the corpus increased.

Nutrients in one-carbon metabolism and urinary arsenic methylation in the National Health and Nutrition Examination Survey (NHANES) 2003-2004.

Exposure to inorganic arsenic (inAs), a potent toxicant, occurs primarily through ingestion of food and water. The efficiency with which it is methylated to mono and dimethyl arsenicals (MMA and DMA) affects toxicity. Folate, vitamins B12 and B6 are required for 1C metabolism, and studies have found that higher levels of these nutrients increase methylation capacity and are associated with protection against adverse health effects from inAs, especially in undernourished populations. Our aim was to determine whether 1C-related nutrients are associated with greater inAs methylation capacity in a general population sample with overall adequate nutrition and low levels of As exposure. Univariate and multivariable regression models were used to evaluate the relationship of dietary and blood nutrients to urinary As methylation in the National Health and Nutrition Examination Survey (NHANES) 2003-2004. Outcome variables were the percent of the sum of inAs and methylated As species (inAs+MMA+DMA) excreted as inAs, MMA, and DMA, and the ratio of MMA:DMA. In univariate models, dietary folate, vitamin B6 and protein intake were associated with lower urinary inAs% and greater DMA% in adults (≥18years), with similar trends in children (6-18). In adjusted models, vitamin B6 intake (p=0.011) and RBC folate (p=0.036) were associated with lower inAs%, while dietary vitamin B12 was associated with higher inAs% (p=0.002) and lower DMA% (p=0.030). Total plasma homocysteine was associated with higher MMA% (p=0.004) and lower DMA% (p=0.003), but not with inAs%; other blood nutrients showed no association with urinary As. Although effect size is small, these findings suggest that 1C nutrients can influence inAs methylation and potentially play an indirect role in reducing toxicity in a general population sample.

Human exposure to dietary inorganic arsenic and other arsenic species: State of knowledge, gaps and uncertainties.

Inorganic arsenic (iAs) is ubiquitous in the environment as arsenite (AsIII) and arsenate (AsV) compounds and biotransformation of these toxic chemicals leads to the extraordinary variety of organoarsenic species found in nature. Despite classification as a human carcinogen based on data from populations exposed through contaminated drinking water, only recently has a need for regulatory limits on iAs in food been recognized. The delay was due to the difficulty in risk assessment of dietary iAs, which critically relies on speciation analysis providing occurrence data for iAs in food - and not simply for total arsenic. In the present review the state of knowledge regarding arsenic speciation in food and diet is evaluated with focus on iAs and human exposure assessment through different dietary approaches including duplicate diet studies, market basket surveys, and total diet studies. The analytical requirements for obtaining reliable data for iAs in food are discussed and iAs levels in foods and beverages are summarized, along with information on other (potentially) toxic co-occurring organoarsenic compounds. Quantitative exposure assessment of iAs in food is addressed, focusing on the need of capturing variability and extent of exposure and identifying what dietary items drive very high exposure for certain population groups. Finally, gaps and uncertainties are discussed, including effect of processing and cooking, and iAs bioavailability.