Letters
RESEARCH LETTER nosed as having ASD. The weighted prevalence of ASD was 2.47%
Prevalence of Autism Spectrum Disorder
Among US Children and Adolescents, 2014-2016
Autism spectrum disorder (ASD) is a serious neurodevelop-
mental disorder resulting in a substantial burden for individu-
als, families, and society.1 Previous surveys have reported a
steady increase in ASD prevalence in US children over the past
2 decades.2-4 However, the most recent estimate from the Au-
tism and Developmental Disabilities Monitoring (ADDM) Net-
work for the first time reported a plateau in ASD prevalence
(1.46%) in 2012, after documenting a continuous increase from
0.67% in 2000 to 1.47% in 2010.2 In this study, we analyzed
nationally representative data to estimate current prevalence
of ASD among US children and adolescents in 2014-2016.
Methods | The National Health Interview Survey (NHIS)5 is a na-
tionally representative annual health survey in the United
States. The NHIS was approved by the research ethics review
board of the National Center for Health Statistics and US Of-
fice of Management and Budget. All respondents provided oral
consent prior to participation. The University of Iowa institu-
tional review board determined that the current study was ex-
empt based on the use of deidentified data.
The NHIS collects data on a broad range of health topics
through in-person household interviews. For each inter-
viewed family in the household, 1 sample child, if any, was ran-
domly selected by a computer program. Information about the
sample child was collected by interviewing an adult, usually
a parent, who was knowledgeable about the child’s health. In
NHIS 2014-2016, the total household response rate ranged from
67.9% to 73.8%, and the conditional response rate for the
sample child component ranged from 91.2% to 92.3%. From
2014 to 2016, respondents were asked: “Has a doctor or health
professional ever told you that [the sample child] had autism,
Asperger’s disorder, pervasive developmental disorder, or au-
tism spectrum disorder?” Responses for children and adoles-
cents aged 3 to 17 years were included.
Prevalence estimates were weighted using survey proce-
dures in SAS (SAS Institute), version 9.4. The sample weights
took into account unequal probabilities of selection and non-
response. P values for overall differences across strata were cal-
culated using the F test. Trends in prevalence were tested using
a logistic regression model with sample weights, which in-
cluded survey year as a continuous variable, and adjusted for
age, sex, and race/ethnicity. A 2-sided P value less than .05 was
considered statistically significant.
Results | Of all eligible participants aged 3 to 17 years in the NHIS
2014-2016, 28 (0.09%) had missing information on ASD diag-
nosis and were excluded. Among the included 30 502 US chil-
dren and adolescents, 711 were reported to have been diag-
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(95% CI, 2.20%-2.73%). The prevalence was 3.63% (95% CI,
3.19%-4.08%) in boys and 1.25% (95% CI, 0.99%-1.51%) in girls;
1.82% (95% CI, 1.42%-2.22%) in Hispanic children and adoles-
cents, 2.76% (95% CI, 2.39%-3.13%) in non-Hispanic white chil-
dren and adolescents, and 2.49% (95% CI, 1.69%-3.29%) in non-
Hispanic black children and adolescents (Table). Across the 3-year
reporting period, the prevalence was 2.24% (95% CI, 1.89%-
2.59%) in 2014, 2.41% (95% CI, 1.98%-2.84%) in 2015, and 2.76%
(95% CI, 2.20%-3.31%) in 2016 (P for trend = .11) (Table).
Discussion | In a large, nationwide population-based study, the
estimated ASD prevalence was 2.47% among US children and
adolescents in 2014-2016, with no statistically significant in-
crease over the 3 years. The observed prevalence was higher
than estimates in previous years from the ADDM,2 although
differences in study design and participant characteristics may
partly explain the prevalence differences. For example, the
NHIS was based on a nationally representative population,
whereas the ADDM was conducted in selected sites. The NHIS
was based on parent report of a physician diagnosis, whereas
the ADDM was based on clinician review of education or health
care evaluations. In the NHIS, the question about ASD changed
in 2014,3 so the NHIS cannot be used to evaluate trends in ASD
prevalence over a longer time. Another limitation is the ascer-
tainment of ASD by the household respondents’ self-reports
of physician diagnosis.
Changes in nonetiologic factors6 (such as diagnostic cri-
teria, public awareness, and referral), as well as in etiologic
factors1 (including genetic and environmental risk factors),
have been postulated to account for the previously observed
increase in ASD prevalence. Continued monitoring of the
prevalence and investigation of changes in risk factors
are warranted.
Guifeng Xu, MD
Lane Strathearn, MBBS, PhD
Buyun Liu, MD, PhD
Wei Bao, MD, PhD
Author Affiliations: Department of Epidemiology, University of Iowa College of
Public Health, Iowa City (Xu, Liu, Bao); Center for Disabilities and Development,
University of Iowa Stead Family Children’s Hospital, Iowa City (Strathearn).
Accepted for Publication: October 26, 2017.
Correction: This article was corrected on January 5, 2018, to update the Results
section and Table with corrected prevalence data.
Corresponding Author: Wei Bao, MD, PhD, Department of Epidemiology,
College of Public Health, University of Iowa, 145 N Riverside Dr, Room S431
CPHB, Iowa City, IA 52242 (wei-bao@uiowa.edu).
Author Contributions: Dr Bao had full access to all of the data in the study and takes
responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Bao.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Xu.
(Reprinted) JAMA January 2, 2018 Volume 319, Number 1 81
 Letters

Table. Prevalence of ASD in US Children and Adolescents, 2014-2016

Characteristic No. With ASD/Total ASD, % (95% CI)a P Value

Overall 711/30 502b 2.47 (2.20-2.73)
Age, y
3-11 403/17 267b 2.49 (2.16-2.83)
.81c
12-17 308/13 235b 2.43 (2.06-2.81)
Sex
Male 545/15 727b 3.63 (3.19-4.08)
<.001c
Female 166/14 775b 1.25 (0.99-1.51)
Race/ethnicityd
Hispanic 140/8111b 1.82 (1.42-2.22)
Non-Hispanic white 405/14 900b 2.76 (2.39-3.13)
.02c
Non-Hispanic black 89/4038b 2.49 (1.69-3.29)
Abbreviation: ASD, autism spectrum
Other 77/3453b 2.48 (1.77-3.19) disorder.
Geographic region a
Prevalence estimates were
Northeast 145/4742 b
3.03 (2.39-3.68) weighted.
b
Midwest 148/6058b 2.45 (1.91-2.98) Unweighted number of participants
c
b
.27 involving all 3 years.
South 234/10 775 2.37 (1.87-2.88) c
P value for overall differences in
West 184/8927b 2.26 (1.84-2.68) prevalence by strata.
ASD prevalence by year d
Race and Hispanic ethnicity were
2014 237/11 082 2.24 (1.89-2.59) self-reported and classified based
on the 1997 Office of Management
2015 240/10 183 2.41 (1.98-2.84) .11e
and Budget Standards.
2016 234/9237 2.76 (2.20-3.31) e
P value for trend.

Critical revision of the manuscript for important intellectual content: Strathearn,
Liu, Bao.
Statistical analysis: Xu.
Obtained funding: Bao.
Administrative, technical, or material support: Bao.
Supervision: Strathearn, Bao.
Conflict of Interest Disclosures: All authors have completed and submitted the
ICMJE Form for Disclosure of Potential Conflicts of Interest and none were
reported.
1. Lyall K, Croen L, Daniels J, et al. The changing epidemiology of autism
spectrum disorders. Annu Rev Public Health. 2017;38:81-102.
2. Christensen DL, Baio J, Van Naarden Braun K, et al; Centers for Disease
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spectrum disorder among children aged 8 years: Autism and Developmental
Disabilities Monitoring Network, 11 sites, United States, 2012. MMWR Surveill
Summ. 2016;65(3):1-23.
3. Zablotsky B, Black LI, Maenner MJ, Schieve LA, Blumberg SJ. Estimated
prevalence of autism and other developmental disabilities following
questionnaire changes in the 2014 National Health Interview Survey. Natl
Health Stat Report. 2015;(87):1-20.
4. Blumberg SJ, Bramlett MD, Kogan MD, Schieve LA, Jones JR, Lu MC.
Changes in prevalence of parent-reported autism spectrum disorder in
school-aged US children: 2007 to 2011-2012. Natl Health Stat Report.
2013;(65):1-11, 1, 11.
5. Parsons VL, Moriarity C, Jonas K, Moore TF, Davis KE, Tompkins L. Design
and estimation for the National Health Interview Survey, 2006-2015. Vital
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6. Hansen SN, Schendel DE, Parner ET. Explaining the increase in the
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COMMENT & RESPONSE
Recurrence of Reflux After Laparoscopic
Antireflux Surgery
To the Editor Dr Maret-Ouda and colleagues assessed the out-
come of laparoscopic antireflux surgery among 2655 patients
who underwent the operation in Sweden between 2005 and
2014.1 They defined failure as postoperative use of antireflux
medications or need for secondary antireflux surgery. The
overall failure rate was 17.7%, and female sex, older age, and
comorbidities were risk factors. Hospital volume of laparo-
scopic antireflux surgery was not associated with risk of
recurrent reflux. They concluded that the high rate of recur-
rent reflux diminishes some of the benefits of the operation.
The study has significant limitations that raise questions
about the validity of the findings and the soundness of
the conclusions.
First, many studies have shown that in the absence of
Barrett esophagus, preoperative symptoms and endoscopic
findings have a sensitivity for gastroesophageal reflux dis-
ease of only 58% to 70%. 2,3 The authors did not provide
any information about the preoperative work up in this
cohort of patients. Second, the most common indication for
laparoscopic antireflux surgery is incomplete relief of symp-
toms with proton pump inhibitor therapy. Based on this
consideration, it is remarkable that 82.3% of patients after
surgery had complete control of symptoms without any
need for medications.
Third, symptoms are a poor indicator of recurrence of
reflux after laparoscopic antireflux surgery, suggesting the
need for objective evidence of recurrence of reflux before
prescribing acid-reducing medications. 4,5 Galvani et al
showed that only 39% of patients with recurrent symptoms
after laparoscopic antireflux surgery had recurrent reflux
when esophageal function tests were performed.4 Further-
more, 68% of patients who were taking acid-reducing medi-
cations after surgery had a normal reflux status as deter-
mined by pH monitoring. Therefore, assessing failure based

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