Child Age at Time of First Maternal Concern and Time to Services Among Children with Autism Spectrum Disorder.

OBJECTIVE: Early treatment of autism spectrum disorder (ASD) can improve developmental outcomes. Children with ASD from minority families often receive services later. We explored factors related to child's age at time of mother's first concerns about child's development and subsequent time to service initiation among children with ASD. METHODS: Analysis included 759 preschool-age children classified with ASD based on comprehensive evaluations. Factors associated with retrospectively reported child age at time of first maternal concern and subsequent time to service initiation were investigated using multiple linear regression and Cox proportional hazards. RESULTS: Earlier maternal concern was associated with multiparity, ≥1 child chronic condition, externalizing behaviors, and younger gestational age, but not race/ethnicity. Time to service initiation was longer for children of non-Latino Black or other than Black or White race and higher developmental level and shorter for children with ≥1 chronic condition and older child age at first maternal concern. CONCLUSION: Parity, gestational age, and child health and behavior were associated with child age at first maternal concern. Knowledge of child development in multiparous mothers may allow them to recognize potential concerns earlier, suggesting that first time parents may benefit from enhanced education about normal development. Race/ethnicity was not associated with child's age when mothers recognized potential developmental problems; hence, it is unlikely that awareness of ASD symptoms causes racial/ethnic disparities in initiation of services. Delays in time to service initiation among children from racial/ethnic minority groups highlight the need to improve their access to services as soon as developmental concerns are recognized.

Risk factors and clinical correlates of sensory dysfunction in preschool children with and without autism spectrum disorder.

Sensory dysfunction is a common feature of autism spectrum disorder (ASD). The objectives of this analysis were to examine risk factors and clinical correlates of sensory dysfunction in preschool children with and without ASD. Children aged 2-5 years were enrolled in a multi-site case-control study. Data were collected in eight areas across the United States in three phases. Caregivers completed an interview with questions on assisted delivery, maternal alcohol use, maternal anxiety during pregnancy, pregnancy weight gain, neonatal jaundice, preterm birth, and child sensory diagnosis given by a healthcare provider. Caregivers also completed an interview and questionnaires on sensory symptoms and clinical correlates of sensory dysfunction in their child. There were 2059 children classified as ASD, 3139 as other developmental delay or disability (DD), and 3249 as population comparison (POP). Caregivers reported significantly more sensory diagnoses and sensory symptoms in children classified as ASD than DD or POP (23.7%, 8.6%, and 0.8%, respectively, for a sensory diagnosis and up to 78.7% [ASD] vs. 49.6% [DD] for sensory symptoms). Maternal anxiety during pregnancy and neonatal jaundice were significantly associated with a sensory diagnosis and certain sensory symptoms in children with ASD and DD. Children's anxiety, attention deficits/hyperactivity, and sleep problems were significantly albeit subtly correlated with both a sensory diagnosis and sensory symptoms in children with ASD and DD. These findings support sensory dysfunction as a distinguishing symptom of ASD in preschool children and identify risk factors and clinical correlates to inform screening and treatment efforts in those with atypical development.

Epidemiology with psychometric spirit: MoBa leads autism's interdisciplinary future-a commentary on Havdahl et al. (2023).

Havdahl et al.'s (2023) Norwegian Mother, Father and Child Cohort Study (MoBa) skill loss study stands out for their creative consideration of scale items to gain a better understanding of skill loss/regression. This commentary outlines how the MoBa team continues to challenge the field by conducting "basic" measurement analyses with their public health longitudinal population data. Their creative use of items, validity-oriented analyses, and transparent reporting of item correlations emulates early-stage scale development in psychometric research, and sets the stage for considering how psychometricians and epidemiologists might more directly work with each other to improve early autism identification research.

Medical Home, Developmental Monitoring/Screening, and Early Autism Identification.

Developmental monitoring/screening predict early identified autism spectrum disorders (ASD), but studies have not yet robustly controlled for a key health care service impacting early identification: medical home. National Surveys of Children's Health (NSCH; 2016-2020) were used to determine the relationship between medical home, developmental monitoring/screening, and identified ASD. NSCH overall medical home variable had a minimal relationship with ASD (under 5 years of age, under 5 identified in last year, under 5 identified over a year prior). Usual source of care was positively, and care coordination negatively, associated with ASD identified in last year, suggesting the overall medical home variable may mask variance from subscales. Research is needed to determine how medical home relates to identification in applied settings.

Differential Performance of Social Communication Questionnaire Items in African American/Black vs. White Children.

Screening for autism spectrum disorder (ASD) is an essential early step in the identification process and inaccurate screening may lead to significant delays in the onset of treatment. Past research has highlighted discrepancies in the performance of ASD screening tools such as the Social Communication Questionnaire (SCQ) among certain racial and ethnic groups. The current study explored the functioning of the SCQ among African American/Black and White respondents based on item level performance on the measure. Differential Item Functioning (DIF) analyses showed that 16 (41%) items of the SCQ functioned differently for African American/Black respondents when compared to White respondents. Implications, such as the potential for delayed diagnosis and treatment, and the influence on downstream outcomes, are discussed.

The complex relationship between greenspace and well-being in children with and without autism.

Greenspace (defined here as canopy coverage) positively correlates with improved well-being in typically developing individuals, but this relationship has not been established in children with autism spectrum disorder (ASD). To investigate this relationship, the current study merged data from the National Survey of Children's Health (2012) with the National Land Cover Database. Across typically developing children, children with ASD, and non-autistic children with special healthcare needs (CSHCN), greenspace unexpectedly negatively correlated with well-being. Further, compared with typically developing children, children with ASD or CSHCN status had lower well-being. Interestingly, typically developing children with conduct problems displayed an unexpected negative relationship (i.e. as greenspace increased whereas well-being decreased), though those without conduct problems showed no relationship. Children with ASD displayed no relationship between greenspace independent of conduct problems. CSHCN displayed non-significant trends suggesting mild positive relationships between greenspace and well-being. These data indicate the relationship between greenspace and well-being is more complex than expected and may depend on the diagnostic traits of the population studied.

Factors Predicting Poor Mental and Physical Health in Parents of Children with Autism Spectrum Disorder: Results from 2016 to 2019 National Survey of Children's Health.

Although poor health has been reported in parents of children with autism spectrum disorder (ASD), most studies excluded fathers and focused on mental health. We combined 2016-2019 data from the National Surveys of Children's Health to determine child and parent characteristics that predict poor mental and physical health in fathers (n = 818) and mothers (n = 2111) of children with ASD. For fathers of children with ASD, higher parenting stress was significantly associated with greater odds of poor physical health, whereas racial and ethnic minorities and living at 400% above the federal poverty were significantly associated with lower odds of poor mental health. For mothers of children with ASD, greater child sleep problems were significantly associated with greater odds of poor physical health, and two-parent household living 400% above the poverty line was significantly associated with reported lower odds of poor mental health. Continued efforts to reduce parenting stress and improve child sleep problems, along with expanding existing services and coverages of ASD services, especially for low-income families, may help reduce the burden on these families, preventing adverse future health outcomes in this population.

Features that best define the heterogeneity and homogeneity of autism in preschool-age children: A multisite case-control analysis replicated across two independent samples.

The heterogeneous nature of children with symptoms of autism spectrum disorder (ASD) makes it difficult to identify risk factors and effective treatment options. We sought to identify behavioral and developmental features that best define the heterogeneity and homogeneity in 2-5-year-old children classified with ASD and subthreshold ASD characteristics. Children were enrolled in a multisite case-control study of ASD. Detailed behavioral and developmental data were gathered by maternal telephone interview, parent-administered questionnaires, child cognitive evaluation, and ASD diagnostic measures. Participants with a positive ASD screen score or prior ASD diagnosis were referred for comprehensive evaluation. Children in the ASD group met study criteria based on this evaluation; children who did not meet study criteria were categorized as having subthreshold ASD characteristics. There were 1480 children classified as ASD (81.6% boys) and 594 children classified as having subthreshold ASD characteristics (70.2% boys) in the sample. Factors associated with dysregulation (e.g., aggression, anxiety/depression, sleep problems) followed by developmental abilities (e.g., expressive and receptive language skills) most contributed to heterogeneity in both groups of children. Atypical sensory response contributed to homogeneity in children classified as ASD but not those with subthreshold characteristics. These findings suggest that dysregulation and developmental abilities are clinical features that can impact functioning in children with ASD and other DD, and that documenting these features in pediatric records may help meet the needs of the individual child. Sensory dysfunction could be considered a core feature of ASD and thus used to inform more targeted screening, evaluation, treatment, and research efforts. LAY SUMMARY: The diverse nature of autism spectrum disorder (ASD) makes it difficult to find risk factors and treatment options. We identified the most dissimilar and most similar symptom(s) in children classified as ASD and as having subthreshold ASD characteristics. Factors associated with dysregulation and developmental abilities contributed to diversity in both groups of children. Sensory dysfunction was the most common symptom in children with ASD but not those with subthreshold characteristics. Findings can inform clinical practice and research.

Are Developmental Monitoring and Screening Better Together for Early Autism Identification Across Race and Ethnic Groups?

National Surveys of Children's Health (NSCH, 2016-2018) data were analyzed to determine if conjoint monitoring and screening showed stronger associations with children under 5 identified with ASD compared to monitoring alone, screening alone or no monitoring or screening; and investigate relationships between monitoring and screening across racial/ethnic subgroups. 86 of 332 children with ASD received their diagnosis in a timeframe suggesting potential monitoring and screening for identification purposes. Analyses showed that conjoint monitoring and screening and monitoring alone, but not screening alone, was associated with early identified ASD cases across race groups. Caution is warranted as interpreting NSCH monitoring and screening items solely for identification purposes is inaccurate in many cases. More research on monitoring with screening is needed.

Race/ethnic inequities in conjoint monitoring and screening for U.S. children 3 and under.

BACKGROUND: Non-White children with developmental disabilities are frequently identified later than White children and therefore miss out on opportunities for early intervention (EI). Recent research indicates that conjoint monitoring and screening is more strongly associated with EI receipt than monitoring or screening alone. OBJECTIVE: To determine if there are racial/ethnic inequities in the conjoint receipt of monitoring and screening. METHOD: A series of survey weighted and stratified logistic regression analyses were conducted on National Surveys of Children's Health (2016-2018) data with conjoint monitoring and screening, screening alone, monitoring alone, and non-receipt as outcomes for children aged 9-23 months of age. The primary predictor was child race/ethnicity (Black, Hispanic, Other, and White). Additional co-variates included child (e.g., Age), caretaker/family (e.g., poverty level), healthcare (e.g., usual source of healthcare), state EI policies, and city metropolitan status. RESULTS: Bivariate analyses indicated significant variation in conjoint monitoring and screening across racial/ethnic groups and covariates. Bivariate analyses showed that Black and Hispanic children had significantly lower odds of conjoint monitoring and screening receipt than White children. Multivariate analyses showed that this relationship was better accounted by co-variates. The health service variable, usual source of healthcare, had the strongest relationship with receipt of conjoint monitoring and screening. CONCLUSIONS: Black and Hispanic children are less likely to receive conjoint monitoring and screening than White children. Analyses investigating the role of usual source of healthcare seem particularly promising for understanding the sources of inequities in monitoring and screening receipt.

Evaluation of sex differences in preschool children with and without autism spectrum disorder enrolled in the study to explore early development.

BACKGROUND AND AIMS: Research in school-aged children, adolescents, and adults with autism spectrum disorder (ASD) has found sex-based differences in behavioral, developmental, and diagnostic outcomes. These findings have not been consistently replicated in preschool-aged children. We examined sex-based differences in a large sample of 2-5-year-old children with ASD symptoms in a multi-site community-based study. METHODS AND PROCEDURES: Based on a comprehensive evaluation, children were classified as having ASD (n = 1480, 81.55 % male) or subthreshold ASD characteristics (n = 593, 70.15 % male). Outcomes were behavior problems, developmental abilities, performance on ASD screening and diagnostic tests, and parent-reported developmental conditions diagnosed before study enrollment. OUTCOMES AND RESULTS: We found no statistically significant sex differences in behavioral functioning, developmental functioning, performance on an ASD screening test, and developmental conditions diagnosed before study enrollment among children with ASD or subthreshold ASD characteristics. Males in both study groups had more parent reported restricted interests and repetitive behaviors than females, but these differences were small in magnitude and not clinically meaningful. CONCLUSIONS AND IMPLICATIONS: Preschool males and females who showed risk for ASD were more similar than different in the outcomes assessed in our study. Future research could examine sex-based differences in ASD phenotypes as children age.

Measuring parent positive support of social communication among toddlers with autism: a systematic review / La medición del apoyo parental positivo a las habilidades de comunicación social en niños pequeños con autismo: una revisión sistemática

There are no systematic reviews of the use of parent-child interaction measures employed within studies examining the effects of parent-mediated intervention on toddlers with autism. Best practices recommend using parent-child interaction measures to assess whether interventions aimed at strengthening parent-child interactions are functioning as intended. A systematic review of parent-mediated early intervention studies of toddlers with autism was conducted. The purpose was to examine the use of parent-child interaction measures to assess parent positive support of toddler social communication and report feasibility characteristics for early interventionist practitioners. Experimental parent-mediated intervention studies of social communication among children with autism younger than 36 months were identified. Measurement approaches to parent support of social communication were quantified. Of 25 studies, only 7 studies reported parent and child outcomes using an instrument designed to measure the construct of parent support of child social communication during observed parent-child interaction. Measures reported are of limited relevance for early intervention practitioners due to administration burden and lack of feasibility for repeated measurement of progress toward increasing parent support of toddler social communication. This study highlights the need for feasible practitioner tools for monitoring progress of parent support of social communication for toddlers with autism

No hay revisiones sistemáticas acerca de las medidas de interacción padres-hijo que se utilizan en los estudios que analizan los efectos de la intervención en niños autistas mediada por los padres. Las mejores prácticas recomiendan controlar la medición de las intervenciones mediadas por los padres, las cuales han sido diseñadas para mejorar las habilidades de comunicación social de los niños con el fin de saber si dichas intervenciones funcionan según lo previsto. El propósito de este artículo es presentar los resultados de una revisión sistemática de la literatura que examina específicamente la medición de la interacción entre padres e hijos en estudios de intervención mediada por padres de niños pequeños con autismo. Se utilizó un enfoque PRISMA para identificar estudios experimentales de intervención mediada por padres, enfocados en la comunicación social de niños pequeños con autismo. Las formas utilizadas para medir el apoyo de los padres de la comunicación social en cada uno de estos estudios fueron cuantificadas. De 25 estudios solo 7 incluyeron una medida de observación directa de la interacción entre padres e hijos en la que se presentaron los índices de comportamiento de padres e hijos. Los métodos de evaluación utilizados para medir la interacción entre padres e hijos en los estudios experimentales publicados tienden a buscar profesionales altamente capacitados y especializados, que además requiere bastante tiempo para codificar. En consecuencia, estas herramientas de medición tienen una utilidad limitada para los profesionales que precisan de herramientas breves y confiables que además tengan una base psicométrica para medir la interacción entre padres e hijos para tomar decisiones basadas en datos sobre si sus intervenciones están teniendo los efectos previstos. El estudio destaca la necesidad de contar con instrumentos de medición con base psicométrica que permitan seguir de manera accesible el progreso del apoyo sobre comunicación social para padres de niños pequeños con autismo

"Watch Me!" Training Increases Knowledge and Impacts Attitudes Related to Developmental Monitoring and Referral Among Childcare Providers.

OBJECTIVES: To evaluate the impact of "Watch Me!" developmental monitoring training on childcare providers' knowledge and attitudes related to monitoring developmental milestones and making recommended referrals when there is a concern about a child's development. METHODS: A pretest-posttest design using web-based surveys was used to assess the impact of "Watch Me!" training on knowledge and attitudes related to conducting five key components of developmental monitoring (tracking development, recognizing delays, talking to parents about development, talking to parents about concerns, and making referrals). Variables included belief that developmental monitoring is important and is part of childcare provider role; perceived knowledge of, access to tools for, and prioritization of developmental monitoring; and ability to list recommended referrals when there is a concern. RESULTS: Childcare providers demonstrated a significant pre-post increase in perceived knowledge and access to the tools to engage in five core components of developmental monitoring after completing "Watch Me!" training. There was also a significant pre-post increase in childcare providers' ability to list the child's doctor as an appropriate referral (39 pre-63% post), but not in the ability to list Part C/Part B programs as an appropriate referral (56 pre-58% post). CONCLUSIONS FOR PRACTICE: "Watch Me!" training may be effective at impacting targeted areas of knowledge and attitude about developmental monitoring among childcare providers in the short term.

Development and utility of the Family-Centered Autism Navigation interview.

LAY ABSTRACT: When a parent learns of their child's autism diagnosis, they may be overwhelmed, confused, and frustrated. Family navigation services are designed to improve access to care. While these services are a promising intervention to enhance well-being and developmental outcomes, there are limited tools that can systematically facilitate the development of a shared navigation plan that prioritizes the concerns of the family. The Family-Centered Autism Navigation semi-structured interview guide is designed for family navigators to triage and prioritize caregiver's needs to coordinate and navigate systems of care after learning of their child's autism spectrum disorder diagnosis. The goals of the Family-Centered Autism Navigation interview are to (1) identify family and child strengths; (2) identify family/caregiver concerns regarding navigation of services and systems following their child's diagnosis of autism; (3) measure change in caregiver knowledge, ability and skill as it relates to understanding, remembering, and evaluating information they receive; and (4) assist with the development of a shared navigation plan. When using the Family-Centered Autism Navigation guide, family navigators and caregivers co-create a family-centered, prioritized action plan that supports and prepares caregivers as they navigate systems of care. This short report describes the development process of the Family-Centered Autism Navigation semi-structured interview guide. We utilized brief interviews (n = 42), expert feedback (n = 13), and quality improvement strategies (n = 2 family navigators) to develop the questions and determine the usability of the Family-Centered Autism Navigation interview in practice.

DSM-5 criteria for autism spectrum disorder maximizes diagnostic sensitivity and specificity in preschool children.

PURPOSE: The criteria for autism spectrum disorder (ASD) were revised in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The objective of this study was to compare the sensitivity and specificity of DSM-IV-Text Revision (DSM-IV-TR) and DSM-5 definitions of ASD in a community-based sample of preschool children. METHODS: Children between 2 and 5 years of age were enrolled in the Study to Explore Early Development-Phase 2 (SEED2) and received a comprehensive developmental evaluation. The clinician(s) who evaluated the child completed two diagnostic checklists that indicated the presence and severity of DSM-IV-TR and DSM-5 criteria. Definitions for DSM-5 ASD, DSM-IV-TR autistic disorder, and DSM-IV-TR Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) were created from the diagnostic checklists. RESULTS: 773 children met SEED2 criteria for ASD and 288 met criteria for another developmental disorder (DD). Agreement between DSM-5 and DSM-IV-TR definitions of ASD were good for autistic disorder (0.78) and moderate for PDD-NOS (0.57 and 0.59). Children who met DSM-IV-TR autistic disorder but not DSM-5 ASD (n = 71) were more likely to have mild ASD symptoms, or symptoms accounted for by another disorder. Children who met PDD-NOS but not DSM-5 ASD (n = 66), or vice versa (n = 120) were less likely to have intellectual disability and more likely to be female. Sensitivity and specificity were best balanced with DSM-5 ASD criteria (0.95 and 0.78, respectively). CONCLUSIONS: The DSM-5 definition of ASD maximizes diagnostic sensitivity and specificity in the SEED2 sample. These findings support the DSM-5 conceptualization of ASD in preschool children.

Influence of Maternal Obesity on Labor Induction: A Systematic Review and Meta-Analysis.

INTRODUCTION: Studies have shown that women with obesity have longer labors. The purpose of this systematic review and meta-analysis is to examine existing evidence regarding labor induction in women with obesity, including processes and outcomes. The primary outcome was cesarean birth following labor induction. Secondary outcomes were the timing and dosage of prostaglandins, the success of mechanical cervical ripening methods, and synthetic oxytocin dose and timing. METHODS: Searches were performed in PubMed, MEDLINE, Embase, CINAHL, EBSCO, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Effects, Google Scholar, and ClinicalTrials.gov. Searches were limited to studies published in English after 1990. Ten studies published between 2009 and 2017 were included in this review. All were observational studies comparing processes and outcomes of induction of labor in relation to maternal body mass index. The primary outcome was cesarean birth following labor induction. We assessed heterogeneity using Cochran's Q test and tau-squared and I2 statistics. We also calculated fixed-effect models to estimate pooled relative risks and weighted mean differences. RESULTS: Ten cohort studies met inclusion criteria; 8 studies had data available for a meta-analysis of the primary outcome. Cesarean birth was more common among women with obesity compared with women of normal weight following labor induction (Mantel-Haenszel fixed-effect odds ratio, 1.82; 95% CI, 1.55-2.12; P < .001). Maternal obesity was associated with a longer time to birth, higher doses of prostaglandins, less frequent success of cervical ripening methods, and higher dose of synthetic oxytocin, as well as a longer time to birth after oxytocin use. DISCUSSION: Women with obesity are more likely than women with a normal weight to end labor induction with cesarean birth. Additionally, women with obesity require longer labor inductions involving larger, more frequent applications of both cervical ripening methods and synthetic oxytocin.

Temperament Similarities and Differences: A Comparison of Factor Structures from the Behavioral Style Questionnaire in Children with and Without Autism Spectrum Disorder.

The majority of studies of temperament in children with autism spectrum disorder (ASD) use scales normed on typical populations. The present study examined a widely used measure of temperament, the Behavioral Style Questionnaire (McDevitt and Carey in Behavioral Styles Questionnaire, Behavioral-Developmental Initiatives Scottsdale, AZ, 1975) to determine whether it contains the temperament traits theorized by its creators. Neither confirmatory nor exploratory factor analysis, using a sample of children with ASD and a population comparison group, identified the theorized nine temperament factors; many items did not strongly load on any of the original factors. A 10 factor solution best described the ASD data and a 9 factor solution best described the typical group's data. There were substantial similarities in the 9 factor solutions, but groups differed from one another enough to question construct similarity for several factors. These results highlight that more basic psychometric research is needed to better understand the BSQ in children with ASD.

Brief Report: The ADOS Calibrated Severity Score Best Measures Autism Diagnostic Symptom Severity in Pre-School Children.

The severity of autism spectrum disorder (ASD) is often measured by co-occurring conditions, such as intellectual disability or language delay, rather than deficits in social interaction, and restricted interests and repetitive behaviors. The Autism Diagnostic Observation Schedule calibrated severity score (ADOS CSS) was created to facilitate comparison of the diagnostic features of ASD independent of related conditions over time. We examined the relationship between the ADOS CSS, ADOS total score, and clinician rated degree of impairment (DOI) in the Study to Explore Early Development. Like others, we confirmed that, among the measures we evaluated, the ADOS CSS was least influenced by developmental functioning and demographic factors and is therefore the best measure of core features of ASD in pre-school children.

State Variability in Diagnosed Conditions for IDEA Part C Eligibility.

An infant or toddler can begin the process of receiving Part C early intervention services by having a diagnosed condition with a high probability of developmental delay (Individuals with Disabilities Education Improvement Act, 2004). How states define those diagnosed conditions that begin the initiation process varies widely. Lists of diagnosed conditions were collected from state Part C websites and Part C coordinators for a descriptive analysis. Across 49 states, the District of Columbia, and 4 territories, a final list of 620 unique conditions was compiled. No single condition was listed by all jurisdictions. Hearing impairment was the condition listed by the most states (n = 38), followed by fetal alcohol syndrome (n = 34). Of the 620 conditions, 168 (27%) were listed by only 1 state, 554 (89%) were listed by fewer than 10 states, and 66 (11%) were listed by 10 or more states. Of these 66 conditions, 47 (71%) were listed by fewer than 20 states. Most of these 66 conditions (n = 48; 72.7%) had a prevalence of "very rare or rare," 8 (12%) were "common," 6 (9%) were "very common," and 4 (6.1%) were "unknown." The wide heterogeneity in the number and type of diagnostic conditions listed across states should be further investigated as it may represent imbalances in children with diagnosed conditions gaining access to Part C evaluations and individualized family service plans and potentially the services themselves across states. In addition, providing ready access to lists of diagnosed conditions is a simple step that could help states and Part C programs facilitate access to services.

Gray space and green space proximity associated with higher anxiety in youth with autism.

This study used ZIP code level data on children's health (National Survey of Children's Health, 2012) and land cover (National Land Cover Database, 2011) from across the United States to investigate connections between proximity to green space (tree canopy), gray space (impervious surfaces), and expression of a critical co-morbid condition, anxiety, in three groups of youth: children diagnosed with autism spectrum disorder (ASD, n = 1501), non-ASD children with special healthcare needs (CSHCN, n = 15,776), and typically developing children (n = 53,650). Both impervious surface coverage and tree canopy coverage increased the risk of severe anxiety in youth with autism, but not CSHCN or typical children. Children with ASD might experience the stress-reducing benefits of nature differently than their typically developing peers. More research using objective diagnostic metrics at finer spatial scales would help to illuminate complex relationships between green space, anxiety, and other co-morbid conditions in youth with ASD.