Autistic Disorder (DSM-IV) by Gender/Sex and Brazilian Public Health System: A 10-Year Retrospective Study
Main Article Content
Abstract
Background: Diagnostic stability in Autistic Disorder (AD) remains a relevant and underexplored topic, particularly in public health systems of middle-income countries.
Objective: To investigate whether diagnostic transience of AD, according to DSM-IV criteria, is associated with origin of care within the public, Brazilian Public Health System versus private service (out of pocket, Non-SUS), and gender/sex.
Methods: Retrospective analysis of medical records from children evaluated between 2009 and 2020 at a tertiary public pediatric hospital and a private psychiatric office in Minas Gerais, Brazil. Inclusion required a DSM-IV diagnosis of AD for at least 36 months. Statistical analyses included Chi-square, Fisher’s Exact, Mann–Whitney, and Kaplan–Meier survival estimates.
Results: Among 906 records analyzed, 186 were excluded, 68 had a transience diagnosis (average 9%): 1F:14M in the BPHS group versus 6F:47M in the non-BPHS group. No statistically significant association was found between diagnostic outcome and BPHS/non-BPHS origin or gender/sex (p > 0.05). Diagnostic transience was associated with a greater number of consultations (older age).
Discussion: Some results were consistent with the literature, such as the higher prevalence of male gender/sex (82.34%), the high frequency of environmental disorders and the median transience percentage (9%) by the 5-year-old median age. The new one is the lack of outcome differences between sex/gender and healthcare systems: BPHS, private, and international literature. The absence of difference in these outcomes is one of the most striking findings, as they differ substantially in access pathways, frequency and intensity of non-medical interventions, and professional specialization in ASD.
Conclusion: Diagnostic transience of AD occurred at similar rates regardless of healthcare origin or gender/sex. These findings raise questions about the importance of all biological markers that can complement clinical assessment and identify the most effective therapeutic methods for each individual affected by ASD. Further longitudinal and biologically integrated studies are necessary to clarify predictors of diagnostic stability and long-term outcomes
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Rutter M, Greenfeld D, Lockyer L. A five to fifteen year follow-up study of infantile psychosis: II. Social and behavioural outcome. The British Journal of Psychiatry. 1967 Nov;113(504):1183-99.
3. Kleinman JM, Ventola PE, Pandey J, Verbalis AD et al. Diagnostic stability in very young children with autism spectrum disorders. Journal of autism and developmental disorders. 2008 Apr;38(4):606-15. doi: 10.1007/s10803-007-0427-8. Epub 2007 Oct 9.
4. Sutera S, Pandey J, Esser EL et al. Predictors of optimal outcome in toddlers diagnosed with autism spectrum disorders. Journal of autism and developmental disorders. 2007 Jan;37(1):98-107. doi: 10.1007/s10803-006-0340-6. Epub 2007 Jan 6.
5. Rondeau E, Klein LS, Masse A, Bodeau N, Cohen D, Guilé JM. Is pervasive developmental disorder not otherwise specified less stable than autistic disorder? A meta-analysis. Journal of Autism and Developmental Disorders. 2011 Sep;41(9):1267-76. doi: 10.1007/s10803-010-1155-z.
6. Howlin P, Goode S, Hutton J, Rutter M. Adult outcome for children with autism. Journal of child psychology and psychiatry. 2004 Feb;45(2):212-29. doi: 10.1111/j.1469-7610.2004.00215.x.
7. Lai MC, Lombardo MV, Ruigrok AN et al. Cognition in males and females with autism: similarities and differences. PLoS One. 2012;7(10):e47198. doi: 10.1 371/journal.pone.0047198. Epub 2012 Oct 17. PMID: 23094036; PMCID: PMC3474800.
8. Ozonoff S, Young GS, Landa RJ et al. Diagnostic stability in young children at risk for autism spectrum disorder: a baby siblings research consortium study. Journal of Child Psychology and Psychiatry. 2015 Sep;56(9):988-98. doi: 10.1111/jcpp.12421. Epub 2015 Apr 29.
9. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
10. Lord C, Risi S, DiLavore PS, Shulman C, Thurm A, Pickles A. Autism from 2 to 9 years of age. Archives of general psychiatry. 2006 Jun;63(6):694-701. doi: 10.1001/archpsyc.63.6.694. PMID: 16754843.
11. Piven J, Harper J, Palmer PA, Arndt S. Course of behavioral change in autism: A retrospective study of high-IQ adolescents and adults. Journal of the American Academy of Child & Adolescent Psychiatry. 1996 Apr 1;35(4):523-9. doi: 10.1097/00004583-19 9604000-00019.
12. Cox A, Klein K, Charman T, Baird G et al. Autism spectrum disorders at 20 and 42 months of age: Stability of clinical and ADI‐R diagnosis. Journal of Child Psychology and Psychiatry. 1999 Jul;40(5): 719-32. PMID: 10433406.
13. Stone WL, Lee EB, Ashford L et al. Can autism be diagnosed accurately in children under 3 years?. The Journal of Child Psychology and Psychiatry and Allied Disciplines. 1999 Feb;40(2):219-26.PMID: 10188704.
14. Eaves LC, Ho HH. The very early identification of autism: Outcome to age 41/2–5. Journal of autism and developmental disorders. 2004 Aug;34(4):367-78. doi: 10.1023/b:jadd.0000037414.33270.a8.
15. Sutera S, Pandey J, Esser EL et al. Predictors of optimal outcome in toddlers diagnosed with autism spectrum disorders. Journal of autism and developmental disorders. 2007 Jan;37(1):98-107. doi: 10.1007/s10803-006-0340-6. Epub 2007 Jan 6.
16. Rondeau E, Klein LS, Masse A, Bodeau N, Cohen D, Guilé JM. Is pervasive developmental disorder not otherwise specified less stable than autistic disorder? A meta-analysis. Journal of Autism and Developmental Disorders. 2011 Sep;41(9):12 67-76. doi: 10.1007/s10803-010-1155-z.
17. Banach R, Thompson A, Szatmari P et al. Brief report: Relationship between non-verbal IQ and gender in autism. Journal of autism and developmental disorders. 2009 Jan;39(1):188-93. doi: 10.1007/s10803-008-0612-4. Epub 2008 Jul 2.
18. Amiet C, Gourfinkel-An I, Bouzamondo A et al. Epilepsy in autism is associated with intellectual disability and gender: evidence from a meta-analysis. Biological psychiatry. 2008 Oct 1;64(7):577-82. doi: 10.1016/j.biopsych.2008.04.030.
19. Lukmanji S, Manji SA, Kadhim S et al. The co-occurrence of epilepsy and autism: A systematic review. Epilepsy & Behavior. 2019 Sep 1;98:238-48. doi: 10.1016/j.yebeh.2019.07.037. Epub 2019 Aug 6.
20. Sebat J, Lakshmi B, Malhotra D et al. Strong association of de novo copy number mutations with autism. Science. 2007 Apr 20;316(5823):445-9. doi: 10.1126/science.1138659. Epub 2007 Mar 15.
21. Hamdan FF, Gauthier J, Araki Y et al. Excess of de novo deleterious mutations in genes associated with glutamatergic systems in nonsyndromic intellectual disability. The American Journal of Human Genetics. 2011 Mar 11;88(3):306-16. doi: 10.1016/j.a jhg.2011.02.001. Epub 2011 Mar 3.
22. Harstad E, Hanson E, Brewster SJ et al. Persistence of autism spectrum disorder from early childhood through school age. JAMA pediatrics. 2023 Nov 1;177(11):1197-205. doi: 10.1001/jamap ediatrics.2023.4003.
23. Camargos Jr, W. The outcome of clinical diagnoses for Autistic Disorder by Sex/Gender: A 10-year retrospective study. Ciências da Saúde, 2025 Mar 29(144)
24. Kočovská E, Billstedt E, Ellefsen A et al. Autism in the Faroe Islands: diagnostic stability from childhood to early adult life. ScientificWorldJournal. 2013;2013: 592371. doi: 10.1155/2013/592371. Epub 2013 Feb 17. PMID: 23476144; PMCID: PMC3586480.
25. Volkmar F, Chawarska K, Klin A. Autism in infancy and early childhood. Annu. Rev. Psychol.. 2005 Feb 4;56(1):315-36. doi: 10.1146/annurev.psych.56.09 1103.070159.
26. Westman Andersson G, Miniscalco C, Gillberg C. Autism in preschoolers: does individual clinician’s first visit diagnosis agree with final comprehensive diagnosis?. The Scientific World Journal. 2013;2013 (1):716267. doi: 10.1155/2013/716267. eCollection 2013.
27. Zwaigenbaum L, Bryson SE, Brian J et al. Stability of diagnostic assessment for autism spectrum disorder between 18 and 36 months in a high‐risk cohort. Autism Research. 2016 Jul;9(7):790-800. doi: 10.1002/aur.1585. Epub 2015 Nov 27.
28. Losapio MC, Pondé MP. Tradução para o português da escala M-CHAT para rastreamento de autismo. J. Ped. 2008 84(3):250-255.
29. Hollander, M., Wolfe, D. A., & Chicken, E. Nonparametric statistical methods. John Wiley & Sons, 2013.
30. Kaplan, E. L.; Meier, P. Nonparametric estimation from incomplete observations. Journal of the American statistical association, v. 53, n. 282, p. 457-481, 1958.
31. Klein, J.P., & Moeschberger, M.L. (2003). Survival Analysis: Techniques for Censored and Truncated Data. Springer.
32. R Core Team (2023). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.
33. De Giacomo A, Fombonne E. Parental recognition of developmental abnormalities in autism. European child & adolescent psychiatry. 1998 Oct;7(3):131-6. doi: 10.1007/s007870050058.
34. Klin A, Lang J, Cicchetti DV, Volkmar FR. Brief report: Interrater reliability of clinical diagnosis and DSM-IV criteria for autistic disorder: results of the DSMIV autism field trial. J Autism Dev Disord.2000 Apr;30(2):163-7. doi: 10.1023/a:1005415823867. PMID: 10832781.
35. Turner LM, Stone WL. Variability in outcome for children with na ASD diagnosis at age 2. J Child Psychol Psychiatry. 2007Aug;48(8):793-802. doi: 10.1 111/j.1469-7610.2007.01744.x. PMID:17683451.
36. Itzchak EB, Zachor DA. Change in autism classification with early intervention: Predictors and outcomes. Research in Autism Spectrum Disorders. 2009 Oct 1;3(4):967-76.
37. Starr, E.M., Popovic, S. & McCall, B.P. Supporting Children with Autism Spectrum Disorder at Primary School: Are the Promises of Early Intervention Maintained?. Curr Dev Disord Rep. 2016; 3:46–56. https://doi.org/10.1007/s40474-016-0069-7
38. Sibley MH, Arnold LE, Swanson JM et al. Variable patterns of remission from ADHD in the multimodal treatment study of ADHD. American Journal of Psychiatry. 2022 Feb;179(2):142-51. doi: 10.1176/appi.ajp.2021.21010032. Epub 2021 Aug 13.