Screening for Hypertension in Children With and Without Autism Spectrum Disorder

Adults with autism are at increased risk for hypertension, cardiovascular disease, and death compared with the general population.^1,2 Although hypertension screening (HS) is recommended for children starting at 3 years of age,³ there are barriers to blood pressure (BP) measurement in children with autism, including sensory discomfort² and comorbid conditions requiring attention during well visits.⁴ We compared the frequency of HS at health maintenance visits for children with and without autism.

Data for this cross-sectional study were obtained from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual surveys of ambulatory physicians using multistage sampling to produce nationally representative estimates. We included visits to office-based practices and hospital outpatient departments for patients aged 3 to 21 years from 2002 to 2018 in which physicians identified the major reason for visit as preventive care; visits to emergency departments were excluded.⁵ Autism was defined using ICD-9 and ICD-10 codes or a positive response to the question, “Does patient now have autism?” The primary outcome was whether BP was measured during the visit based on physician documentation. For reference to other chronic diseases, we report the frequency of HS during preventive visits for children with attention-deficit/hyperactivity disorder, asthma, depression, diabetes, cerebral palsy, epilepsy, and obesity. The National Center for Health Statistics Ethics Review Board authorized these surveys with waivers of informed consent. The Yale University institutional review board deemed this study exempt from review. This study followed the STROBE reporting guideline.

Proportions were compared using the χ² test. We used multivariable logistic regression to evaluate the association between autism and HS after adjusting for age, sex, race, year, physician specialty, insurance, number of chronic conditions, diabetes, and obesity. We assessed the association between autism and other preventive services. We defined statistical significance as 2-sided P < .05. Data were analyzed accounting for the complex sampling design from October 2021 to March 2022 using Stata/SE, version 17.0.

Of 44 501 visits, 0.5% (95% CI, 0.4%-0.7%) involved children with autism, with median (IQR) age in years (11 [6-18] vs 12 [6-17]), median (IQR) previous visits in past year (1 [0-2] vs 2 [1-4]), and visits with an obesity diagnosis (4.8% [95% CI, 1.6%-13.7%] vs 4.0% [95% CI, 3.6%-4.5%]) similar for visits with and without an autism diagnosis; visits with autism involved more males (80.8% [95% CI, 69.4%-88.6%] vs 41.7% [40.3%-43.2%]). HS occurred in 55.8% (95% CI, 37.3%-72.8%) of visits with autism vs 75.7% (95% CI, 74.1%-77.2%) without autism (P = .02) (Figure). When divided into 2 periods, HS increased over time for children without autism but not for children with autism. HS for children with other conditions occurred at least as often as for children without that condition. Among visits with BP measured, hypertensive readings³ occurred in 16.7% (95% CI, 7.9-31.8) with autism and 15.2% (95% CI, 14.3-16.2) without autism (P = .80). In the multivariable model, autism remained significantly associated with decreased odds of HS (odds ratio, 0.39; 95% CI, 0.17-0.89) (Table) and was associated with decreased odds of height measurement, nutrition counseling, and exercise counseling.

In this national sample of pediatric preventive visits, HS was less likely to occur during visits for children with autism vs visits for children without autism. Our findings complement literature describing gaps in preventive care for children with autism, including decreased vaccination rates and missed well-child visits.⁶ Home BP monitoring may be a feasible alternative to in-office measurement for children with autism.²

Limitations include the cross-sectional design, lack of previous BP values, and small sample of visits with an autism diagnosis. Defining autism by physician documentation may introduce misclassification bias, with more severely affected children being more likely to be identified; however, we used broad ICD-9 and ICD-10 criteria to capture a spectrum of autism phenotypes. Further research is needed to identify barriers and test interventions to improve HS and cardiovascular disease prevention in children with autism.

Accepted for Publication: February 18, 2022.

Published: April 6, 2022. doi:10.1001/jamanetworkopen.2022.6246

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Nugent JT et al. JAMA Network Open.

Corresponding Author: James T. Nugent, MD, MPH, Clinical and Translational Research Accelerator, Department of Medicine, Yale University School of Medicine, 60 Temple St, Ste 6C, New Haven, CT 06510 (james.nugent@yale.edu).

Author Contributions: Dr Nugent had full access to all the data and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nugent, Greenberg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Nugent, Greenberg.

Critical revision of the manuscript for important intellectual content: Bakhoum, Ghazi, Greenberg.

Statistical analysis: Nugent.

Administrative, technical, or material support: Greenberg.

Supervision: Bakhoum, Ghazi, Greenberg.

Conflict of Interest Disclosures: Dr Bakhoum reported received funding from the American Heart Association and the National Institute of Diabetes and Digestive and Kidney Diseases. Dr Ghazi reported receiving an American Heart Association Postdoctoral Fellowship Award. Dr Greenberg reported receiving funding from the National Institute of Diabetes and Digestive and Kidney Diseases and the Charles Hood Foundation.