This study used the Stockholm Youth Cohort, a total population cohort (N = 364,957), to describe patterns and predictors of qualification for upper secondary education, defined by passing graduation ...grades in core compulsory school subjects in contemporary young individuals diagnosed with autism spectrum disorders without intellectual disability (n = 6138). At the expected age for graduation, 16 years, 29% (adjusted rate difference 95% confidence interval (28.0–30.0)) fewer autistic than non-autistic individuals were qualified for upper secondary education (57% and 86%, respectively). Comorbid attention-deficit hyperactivity disorder further increased this difference. Within the group of autistic students without intellectual disability, female sex and lower family income were associated with non-qualification for upper secondary education. The proportion of students with autism without intellectual disability who qualified for upper secondary education increased at age 20. These findings underline the need for improved support for students with a diagnosis of autism without intellectual disability in mainstream education.
Lay abstract
Obtaining a quality education is important for any individual’s chances of leading a healthy and thriving life. Currently, educational policies in many countries underscore the rights of students with autism to be educated in mainstream schools. While there is some knowledge on school outcomes among students with autism from older studies, little is known about rates of qualification for upper secondary education among children with autism in mainstream schools today. This lack of knowledge is problematic since autism is diagnosed more widely, and prior evidence may not be relevant for individuals with autism and their families today. Using Swedish registers, we therefore examined this in a study including all children and young people in Stockholm County in 2001 through 2011. We found that about two thirds of children with autism without intellectual disability qualified for upper secondary education at the expected age, in comparison with about nine in ten among typically developing peers. We also found that girls with autism had further difficulties obtaining such qualification than boys and that those who were additionally diagnosed with attention-deficit hyperactivity disorder were particularly at risk of non-qualification. Finally, students with autism without intellectual disability had a greater chance of completing compulsory education if given an extended period to graduate. These findings underline the need for supportive interventions for children with autism during compulsory school. They may also challenge the inclusive education policy adopted by majority of western countries, at least in the wake of addressing special needs in mainstream schooling.
Autism is one of the most prevalent neurodevelopmental conditions worldwide, and autistic individuals face challenges in daily functioning related to differences and difficulties in social ...interaction and communication along with intense interests and behaviours. In the past, this heterogenous and common condition was considered to be rare. Outcomes in education and mental ill-health are not fully understood in the more recent cohorts.This thesis investigates two domains of outcomes in young autistic individuals: educational performance, focusing on compulsory/primary and upper secondary mainstream schooling in autistic students without intellectual disability in study I and study III; and self-harm behaviours including their characteristics and link with suicide in studies II and IV.All four studies in this thesis are observational, prospective, register-based total-population cohort studies. Studies I-III utilize rich data collected in Stockholm Youth Cohort, a total population cohort of children aged 0 – 17 years resident in Stockholm County in Sweden, from 2001 to 2011 (N = 736,180). A range of national and regional records were linked using personal identification numbers that are assigned to every Swedish resident. In Study IV we linked the Total Population Register to four longitudinal, nationwide, registers in Sweden: The Multi-Generation Register, The Longitudinal Integration Database for Occupational research, and The Cause-of-Death Register, and identified study population of adolescents and younger adults born between 1984-2009. We follow-up this population (N = 2,822,789) until December 31st, 2021, when the oldest study participants were aged 37 years.In Study I we observed a significantly lower proportion of autistic students (57 %; p < 0.05) meeting eligibility criteria for upper secondary education as compared to their non-autistic peers (86 %; p < 0.05). At the end of secondary mainstream school (Study III) autistic students were almost three times less likely to complete the school (OR 2.9 95 % CI 2.70; 3.15) compared to their non-autistic peers. In both studies females and students with co-occurring attention deficit hyperactivity disorder were at particularly high risks of adverse outcomes. Study II observed discrepancies between self-harm, sufficiently severe to lead to hospitalization: nearly 3 % of autistic individuals had been hospitalized at least once for self-harm between the ages of 10 and 27 years, compared with 0.8 % of their non-autistic peers. In study IV, autistic individuals with a record of self-harm were found to be at substantially higher risk of suicide (HR 22.9 95 % CI 19.5 - 26.9) than both non-autistic self-harmers HR 16.2 95 % CI 14.9 - 17.5 and autistic individuals who did not engage in self-harm (HR 1.8 95 % CI 1.5 - 2.1), as compared to non-autistic individuals without a record of self-harm.The findings of this thesis suggest that autistic students without intellectual disability attending mainstream education in Stockholm (compulsory and upper secondary) are at a higher risk of low educational attainment in terms of formal requirements for continuation of schooling or work. Autistic females and students with co-occurring attention deficit hyperactivity disorder are particularly sensitive to this underachievement.Autism was associated with increased risk of self-harm independently of comorbid ADHD, depression and anxiety disorders, and the likelihood of self-harm in autism was as high as in these conditions. Choice of methods used to self-harm by autistic, may be more lethal that those used by non-autistic individuals. Self-harm in autistic individuals conveys particularly increased risk of consecutive suicide, even more so than in non-autistic peers. Together, these findings indicate that self-harm which is an important predictor of suicide in the general population, should be a matter of great clinical concern if present in young autistic individuals, and that the needs of autistic self-harmers should be included in clinical guidelines and risk assessment processes.
Abstract Higher education is an increasingly necessary achievement to attain employment. However, even in cases where a student has the academic skills to succeed, educational environments may not ...support students across all other domains necessary for education success, including social and communication needs. This is especially true for students with disabilities and autistic students, where the rate of completion of non-compulsory education is unknown. We used the Stockholm Youth Cohort (children aged 0–17 years from 2001 to 2011), a total population cohort ( N = 736,180) including 3,918 autistic individuals, to investigate the association between autism without intellectual disability and completion of upper secondary education. We assessed the impact of sex and co-occurring Attention-Deficit/Hyperactivity Disorder (ADHD) on this association. By age 20 years (the expected age of completion), 68% of autistic students and 91% of non-autistic students admitted to upper secondary education had completed. In logistic regression models adjusted for student demographics, autistic students had almost five-fold higher odds of not completing secondary school (OR 4.90, 95% CI 4.56 5.26) compared to their non-autistic peers. Autistic students with ADHD had particularly high odds of non-completion of upper secondary school. Autistic students without intellectual disability attending mainstream education are substantially less likely to complete upper secondary education as compared to their peers. These findings have implications for the appraisal of how inclusive school policies serve autistic students’ academic and social needs, ultimately addressing population health and independent living.
Abstract Introduction Both suicide and self‐harm are disproportionately common in autistic people. Sex differences in risk of self‐harm and suicide are observed in the general population, but ...findings are mixed for autistic people. Self‐cutting may be a particularly risky self‐harm behaviour for suicide in autistic people. We aimed to explore sex differences and differences in method of self‐harm in the association between self‐harm and suicide in autistic and non‐autistic adolescents and young adults. Methods We used a total population register of 2.8 million Swedish residents. Participants were followed from age 12 until December 2021 for medical treatment because of self‐harm, and death from suicide. We used Cox proportional hazard regression models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of death from suicide following self‐harm, and Relative Excessive Risk due to Interaction (RERI) to explore the interaction between self‐harm and autism in females and males. Results We identified 85,143 autistic individuals (31,288 female; 53,855 male) and 2,628,382 non‐autistic individuals (1,286,481 female; 1,341,901 male) aged 12–37 years. Incidence of suicide following self‐harm was higher in autistic males (incidence per 100,000 risk‐years = 169.0 95% CI 135.1, 211.3) than females (125.4 99.4, 158.3). The relative risk was higher for autistic females (HR 26.1 95% CI 20.2, 33.7) than autistic males (12.5 9.9, 15.8). An additive effect of both autism and self‐harm was observed in both females (RERI = 9.8) and males (2.0). Autistic individuals who self‐harmed through cutting were at greatest risk of death from suicide (HR 25.1 17.9, 35.2), compared to other methods. Conclusion Autistic males and females are at increased risk of death from suicide following severe self‐harm, particularly self‐cutting.
Objective
Self‐harm among young autistic individuals is a clinical challenge, and the risk of premature death by suicide is strongly increased in this group. Using the advantage of total‐population ...and family‐based data, we investigated whether autism per se is a risk factor for self‐harm independently of psychiatric comorbidities and how it differs from self‐harm in non‐autistic individuals.
Methods
We used The Stockholm Youth Cohort, a total‐population register study, including all residents in Stockholm County aged 0–17 years between 2001 and 2011.Study participants were followed from age 10 to 27 for hospital admissions because of self‐harm. We used modified Poisson regression to calculate relative risks (RR) using robust standard error to derive 95% confidence intervals (CI).
Results
In all, 410,732 individuals were included in the cohort (9,070 with a diagnosis of autism). Autistic individuals had a fivefold increased adjusted relative risk of self‐harm (RR 5.0 95% CI 4.4–5.6). The risk increase was more pronounced for autism without intellectual disability and particularly high for self‐cutting 10.2 7.1–14.7 and more violent methods 8.9 5.2–15.4. The association between autism and self‐harm was independent of, but clearly exacerbated by comorbid psychiatric conditions. It was of similar magnitude as risks linked to these conditions per se, and not explained by shared familial factors.
Conclusion
Self‐harm severe enough to present to medical services is as common in autistic youth as in those with depression or ADHD. Potentially more lethal methods are more likely to be used of autistic self‐harmers.
Importance
Little is known about the specific timing and sequence of incident psychiatric comorbidities at different stages of dementia diagnosis.
Objectives
To examine the temporal risk patterns of ...psychiatric disorders, including depression, anxiety, stress-related disorders, substance use disorders, sleep disorders, somatoform/conversion disorders, and psychotic disorders, among patients with dementia before, at the time of, and after receipt of a diagnosis.
Design, Setting, and Participants
This population-based, nationwide cohort study analyzed data from 796 505 participants obtained from 6 registers between January 1, 2000, and December 31, 2017, including the Swedish registry for cognitive/dementia disorders. Patients with dementia were matched on year of birth (±3 years), sex, and region of residence with up to 4 controls. Data were analyzed between March 1, 2023, and August 31, 2023.
Exposures
Any cause of dementia and dementia subtypes.
Main Outcomes and Measures
Flexible parametric survival models to determine the time-dependent risk of initial diagnosis of psychiatric disorders, from 7 years prior to dementia diagnosis to 10 years after diagnosis. Subgroup analysis was conducted for psychiatric drug use among persons receiving a diagnosis of dementia from January 1, 2011, to December 31, 2012.
Results
Of 796 505 patients included in the study (mean SD age at diagnosis, 80.2 8.3 years; 448 869 (56.4%) female), 209 245 had dementia, whereas 587 260 did not, across 7 824 616 person-years. The relative risk of psychiatric disorders was consistently higher among patients with dementia compared with control participants and began to increase from 3 years before diagnosis (hazard ratio, HR, 1.72; 95% CI, 1.67-1.76), peaked during the week after diagnosis (HR, 4.74; 95% CI, 4.21-5.34), and decreased rapidly thereafter. Decreased risk relative to controls was observed from 5 years after diagnosis (HR, 0.93; 95% CI, 0.87-0.98). The results were similar for Alzheimer disease, mixed dementia, vascular dementia and unspecified dementia. Among patients with dementia, markedly elevated use of psychiatric medications was observed in the year leading up to the dementia diagnosis and peaked 6 months after diagnosis. For example, antidepressant use was persistently higher among patients with dementia compared with controls, and the difference increased from 2 years before dementia diagnosis (15.9% vs 7.9%,
P
< .001), peaked approximately 6 months after dementia diagnosis (29.1% vs 9.7%,
P
< .001), and then decreased slowly from 3 years after diagnosis but remained higher than controls 5 years after diagnosis (16.4% vs 6.9%,
P
< .001).
Conclusions and Relevance
The findings of this cohort study that patients with dementia had markedly increased risks of psychiatric disorders both before and after dementia diagnosis highlight the significance of incorporating psychiatric preventative and management interventions for individuals with dementia across various diagnostic stages.
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