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Lower Risk of Burn Injury in Children and Adolescents with Autism Spectrum Disorder: A Nationwide Population-Based Study

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Title: Lower Risk of Burn Injury in Children and Adolescents with Autism Spectrum Disorder: A Nationwide Population-Based Study
Language: English
Authors: Chan, Hsiang-Lin, Hsieh, Yi-Hsuan, Lin, Chiao-Fan, Liang, Hsin-Yi, Lee, Su-Shin, Weng, Jun-Cheng, Lee, Min-Jing, Chen, Yi-Lung (ORCID 0000-0003-2934-5814), Chen, Vincent Chin-Hung, Gossop, Michael
Source: Journal of Autism and Developmental Disorders. Feb 2023 53(2):648-655.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 8
Publication Date: 2023
Document Type: Journal Articles
Reports - Research
Descriptors: Fire Protection, Injuries, Autism Spectrum Disorders, Children, Adolescents, Foreign Countries
Geographic Terms: Taiwan
DOI: 10.1007/s10803-020-04859-9
ISSN: 0162-3257
1573-3432
Abstract: Little research has examined burn injury in the pediatric population with autism spectrum disorder (ASD). We used data from Taiwan's National Health Insurance Research Database to identify 15,844 participants aged <18 years with ASD and 130,860 participants without ASD. Our results revealed that the hazard ratios differed across three age ranges. The ASD group had a lower risk of burn injury than the non-ASD group when they were less than 6 years of age, a higher risk from 6 years to 12 years of age, and no difference when they were older than 12 years of age. More research is required to study the characteristics and causes of burn injury in the pediatric population with ASD.
Abstractor: As Provided
Entry Date: 2023
Accession Number: EJ1368740
Database: ERIC
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  Value: &lt;anid&gt;AN0162013108;aut01feb.23;2023Feb23.23:34;v2.2.500&lt;/anid&gt; &lt;title id=&quot;AN0162013108-1&quot;&gt;Lower Risk of Burn Injury in Children and Adolescents with Autism Spectrum Disorder: A Nationwide Population-Based Study&#160;&lt;/title&gt; &lt;p&gt;Little research has examined burn injury in the pediatric population with autism spectrum disorder (ASD). We used data from Taiwan&#39;s National Health Insurance Research Database to identify 15,844 participants aged &amp;lt;18 years with ASD and 130,860 participants without ASD. Our results revealed that the hazard ratios differed across three age ranges. The ASD group had a lower risk of burn injury than the non-ASD group when they were less than 6 years of age, a higher risk from 6 years to 12 years of age, and no difference when they were older than 12 years of age. More research is required to study the characteristics and causes of burn injury in the pediatric population with ASD.&lt;/p&gt; &lt;p&gt;Keywords: Burn injury; Autism; Cohort study&lt;/p&gt; &lt;p&gt;Yi-Lung Chen contributes equally to Vincent Chin-Hung Chen as corresponding author.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-2&quot;&gt;Introduction&lt;/hd&gt; &lt;p&gt;Pediatric burn injury can be devastating, with the potential for severe health consequences and mortality (Arbuthnot and Garcia [&lt;reflink idref=&quot;bib3&quot; id=&quot;ref1&quot;&gt;3&lt;/reflink&gt;]). The bimodal age distribution for individuals with the highest burn injury risk includes the pediatric population aged 1–15 years, representing one-fourth of all people with burn injuries (Kessler et al. [&lt;reflink idref=&quot;bib21&quot; id=&quot;ref2&quot;&gt;21&lt;/reflink&gt;]). Burn injury was also the third leading cause of unintentional injury mortality among children in the United States in 2018 (Centers for Disease Control and Prevention [&lt;reflink idref=&quot;bib7&quot; id=&quot;ref3&quot;&gt;7&lt;/reflink&gt;]). Scald injuries were most common in children younger than 5 years, whereas flame-related injuries were more common in older children (Flaxman et al. [&lt;reflink idref=&quot;bib14&quot; id=&quot;ref4&quot;&gt;14&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;Few studies have focused on the association between pediatric burn injury and neurodevelopmental disorders. On the basis of Ohio Medicaid claims data, Chen et al. observed that physically and mentally disabled children were nearly twice as likely to sustain burn injuries than nondisabled children (odds ratio [OR] = 1.80; 95% confidence interval [CI]: 1.50–2.17) (Chen et al. [&lt;reflink idref=&quot;bib8&quot; id=&quot;ref5&quot;&gt;8&lt;/reflink&gt;]). Alden et al. used longitudinal data with a 4-year follow-up from the Burn Center&#39;s National Trauma Registry to investigate burn injury in individuals with early-onset neurological diseases, including autism (Alden et al. [&lt;reflink idref=&quot;bib2&quot; id=&quot;ref6&quot;&gt;2&lt;/reflink&gt;]). The authors compared age, sex, burn severity, and treatment between individuals with early-onset neurological diseases and those without. The study identified no significant difference in age or percentage of total body surface area involvement between those with and without neurological diseases. Attention-deficit/hyperactivity disorder (ADHD) is one of most common psychiatric comorbidities in those with autism spectrum disorder (ASD), and the rates of comorbidity range from 30 to 70% (Mosner et al. [&lt;reflink idref=&quot;bib33&quot; id=&quot;ref7&quot;&gt;33&lt;/reflink&gt;]; Rau et al. [&lt;reflink idref=&quot;bib37&quot; id=&quot;ref8&quot;&gt;37&lt;/reflink&gt;]). The pediatric population with ADHD has received more attention than the population with ASD for their burn risk, injury severity, pattern, and etiology (Thomas et al. [&lt;reflink idref=&quot;bib42&quot; id=&quot;ref9&quot;&gt;42&lt;/reflink&gt;]; Mangus et al. [&lt;reflink idref=&quot;bib29&quot; id=&quot;ref10&quot;&gt;29&lt;/reflink&gt;]; Fritz and Butz [&lt;reflink idref=&quot;bib15&quot; id=&quot;ref11&quot;&gt;15&lt;/reflink&gt;]; Badger et al. [&lt;reflink idref=&quot;bib5&quot; id=&quot;ref12&quot;&gt;5&lt;/reflink&gt;]). The major causes of burn injury in individuals with ADHD may be related to impulsive behaviors and alertness deficits (Thomas et al. [&lt;reflink idref=&quot;bib42&quot; id=&quot;ref13&quot;&gt;42&lt;/reflink&gt;]), and psychostimulant treatment may reduce the risk of burns in individuals with ADHD (Thomas et al. [&lt;reflink idref=&quot;bib42&quot; id=&quot;ref14&quot;&gt;42&lt;/reflink&gt;]; Fritz and Butz [&lt;reflink idref=&quot;bib15&quot; id=&quot;ref15&quot;&gt;15&lt;/reflink&gt;]). These results suggested that individuals with neurodevelopmental disorders have a higher risk of burns than individuals in the general pediatric population.&lt;/p&gt; &lt;p&gt;ASD is a neurodevelopmental disease characterized by sociocommunication deficits and rigid interests and behaviors (Lai et al. [&lt;reflink idref=&quot;bib22&quot; id=&quot;ref16&quot;&gt;22&lt;/reflink&gt;]). Studies on injury risk in youths with ASD have reported inconsistent findings. Lee et al. observed that preschool children with ASD were twice as likely to sustain an injury than controls (OR = 2.15; 95% CI: 1.00–4.60). The injury types defined in that study included accidents, injury, and poisoning (Lee et al. [&lt;reflink idref=&quot;bib26&quot; id=&quot;ref17&quot;&gt;26&lt;/reflink&gt;]). McDermott et al. obtained data from 1610 individuals with ASD and 91,571 controls insured by Medicaid (McDermott et al. [&lt;reflink idref=&quot;bib31&quot; id=&quot;ref18&quot;&gt;31&lt;/reflink&gt;]) and reported the overall risk of injury in children with ASD needing emergency department or hospital treatment was mildly elevated (OR = 1.20; 95% CI: 1.04–1.39) (McDermott et al. [&lt;reflink idref=&quot;bib31&quot; id=&quot;ref19&quot;&gt;31&lt;/reflink&gt;]). The risk of burn injury was also higher in children with ASD than in controls (0.43% vs. 0.30%), and the authors explained that no further adjustment was performed for burns because the event was rare (7 cases) (McDermott et al. [&lt;reflink idref=&quot;bib31&quot; id=&quot;ref20&quot;&gt;31&lt;/reflink&gt;]). In contrast, Brenner et al. surveyed unintentional injury risk (including fire or burns) in youth with disabilities and did not observe increased injury risk in youth with ASD compared to those without disabilities (OR = 0.98; 95% CI: 0.44–1.52) (Brenner et al. [&lt;reflink idref=&quot;bib6&quot; id=&quot;ref21&quot;&gt;6&lt;/reflink&gt;]). Kalb et al. observed that children and adolescents with ASD had a lower risk of injury-related emergency unit visits than youths without ASD or intellectual disabilities (OR = 0.52; 95% CI: 0.50–0.54) (Kalb et al. [&lt;reflink idref=&quot;bib19&quot; id=&quot;ref22&quot;&gt;19&lt;/reflink&gt;]). The statistical data across all injury types revealed a higher rate of burn injury in those with ASD than in controls (1.1% vs. 0.9%) (Kalb et al. [&lt;reflink idref=&quot;bib19&quot; id=&quot;ref23&quot;&gt;19&lt;/reflink&gt;]). Jain et al. analyzed a large sample (33,565 youths with ASD and 138,876 controls) based on claims data from a commercial health plan in the United States. After adjustments for confounding factors, including sociodemographic data and comorbid diseases, the authors reported a lower injury risk (HR = 0.89; 95% CI: 0.87–0.91) in children and adolescents with ASD. This finding emphasized the importance of adjusting for cooccurring conditions (Jain et al. [&lt;reflink idref=&quot;bib18&quot; id=&quot;ref24&quot;&gt;18&lt;/reflink&gt;]). Moreover, a study on young children (30–68 months old) revealed that those with ASD had a similar injury risk compared to those in the general population. The risk of burn injury was lower in children with ASD than in those in the general population (2.2% vs. 2.8%) (DiGuiseppi et al. [&lt;reflink idref=&quot;bib10&quot; id=&quot;ref25&quot;&gt;10&lt;/reflink&gt;]), although these results were not statistically analyzed, perhaps as a result of the small sample size. Most studies included burn injury as one injury type and reported inconsistent results of burn risk (McDermott et al. [&lt;reflink idref=&quot;bib31&quot; id=&quot;ref26&quot;&gt;31&lt;/reflink&gt;]; Brenner et al. [&lt;reflink idref=&quot;bib6&quot; id=&quot;ref27&quot;&gt;6&lt;/reflink&gt;]; Kalb et al. [&lt;reflink idref=&quot;bib19&quot; id=&quot;ref28&quot;&gt;19&lt;/reflink&gt;]; Jain et al. [&lt;reflink idref=&quot;bib18&quot; id=&quot;ref29&quot;&gt;18&lt;/reflink&gt;]; DiGuiseppi et al. [&lt;reflink idref=&quot;bib10&quot; id=&quot;ref30&quot;&gt;10&lt;/reflink&gt;]). To address the aforementioned concerns, we conducted a national cohort study with adjustments for confounders to examine whether a differential risk of burn injury would be observed between children and adolescents with ASD and those in the general pediatric population.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-3&quot;&gt;Method&lt;/hd&gt; &lt;p&gt;&lt;/p&gt; &lt;hd id=&quot;AN0162013108-4&quot;&gt;Data Source&lt;/hd&gt; &lt;p&gt;The data used in this nationwide cohort study were obtained from Taiwan&#39;s National Health Insurance Research Database (NHIRD) under the aegis of the National Health Research Institute (NHRI). The NHIRD has a coverage rate of 99.5% of the national population and has collected data since March 1, 1995 (Ng [&lt;reflink idref=&quot;bib34&quot; id=&quot;ref31&quot;&gt;34&lt;/reflink&gt;]). The database contains comprehensive data on individuals, including demographic information, dates of clinic visits and hospitalizations, disease diagnosis codes, procedure codes, and details of prescriptions. Although no validation study has been conducted with regard to ASD, several validation studies have confirmed that the dataset has high sensitivity (&amp;gt;0.8) for common conditions and severe diseases (e.g., acute ischemic stroke, epilepsy, pneumonia, acute myocardial infarction, hypertension, and diabetes) although the sensitivity was unsatisfactory (&amp;lt;0.7) for renal dysfunction and coronary artery disease (Hsieh et al. [&lt;reflink idref=&quot;bib16&quot; id=&quot;ref32&quot;&gt;16&lt;/reflink&gt;]).&lt;/p&gt; &lt;hd id=&quot;AN0162013108-5&quot;&gt;Exposure Assessment&lt;/hd&gt; &lt;p&gt;For this study, we used the entire NHRI database to identify ASD children and adolescents and the Longitudinal Health Insurance Database 2005 (LHID2005) to identify non-ASD control groups. The LHID2005 is a small part of the data from the entire NHRI database, which contains data for 1,000,000 enrollees randomly sampled from the entire NHRI database (&lt;emph&gt;N&lt;/emph&gt; = 25,678,998) in 2005. After the sampling process, it collected the data of these 1,000,000 enrollees from the entire NHRI database from 1997 to 2013. The distribution of sex and age of the sampled enrollees in the LHID2005 did not differ significantly from that of the entire NHRI dataset in 2005. We used a three-year (from 1997 to 1999) washout period for the NHRI database and LHID2005. We searched the NHRI dataset and identified 15,844 children and adolescents (under 18 years old) who were diagnosed with ASD (International Classification of Disease, Ninth. Revision, Clinical Modification, ICD-9-CM code: 299) from 2000 to 2010, whereas children and adolescents without ASD were selected from the LHID2005 by removing those who were diagnosed as having ASD from 2000 to 2010. As a result, 130,860 participants were selected from the LHID2005 (Fig. 1). This study was reviewed and approved by the Institutional Review Board of Chang Gung Memorial Hospital.&lt;/p&gt; &lt;p&gt;Graph: Fig. 1 Flow chart of participant selection. ASD autism spectrum disorder, LHID Longitudinal Health Insurance Database&lt;/p&gt; &lt;hd id=&quot;AN0162013108-6&quot;&gt;Main Outcome Assessment&lt;/hd&gt; &lt;p&gt;The main outcome of this study was the incidence of age of diagnosis (AoD) for the first burn injury (ICD-9-CM codes: 940–949) from our participants over the period from 2000 to 2013. Participants with a diagnosis of burn injury before a diagnosis of ASD were excluded.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-7&quot;&gt;Covariates&lt;/hd&gt; &lt;p&gt;Several covariates that have been reported to be associated with ASD and burn injury were selected, including sex and age (by the end of 2013) (Kalb et al. [&lt;reflink idref=&quot;bib19&quot; id=&quot;ref33&quot;&gt;19&lt;/reflink&gt;]), ADHD (ICD-9-CM code: 314), tic disorders (ICD-9-CM code: 307.2), epilepsy (ICD-9-CM code: 345), intellectual disability (ICD-9-CM codes: 317–319) (Alden et al. [&lt;reflink idref=&quot;bib2&quot; id=&quot;ref34&quot;&gt;2&lt;/reflink&gt;]), and the use of sedatives or anxiolytics (Anatomical Therapeutic Chemical codes: N05B/N05C). The status of these covariates for participants were examined during the follow-up period from 2000 to 2013.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-8&quot;&gt;Statistical Analysis&lt;/hd&gt; &lt;p&gt;All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC, USA). Descriptive results are presented as frequencies and percentages for categorical variables and as the means with standard deviations and medians with interquartile ranges for continuous variables. To investigate the risk of a first burn injury in the ASD group compared with the non-ASD group, we first conducted a Kaplan-Meier analysis using the log-rank test and a Cox proportional hazards model to adjust for possible covariates. For the Cox proportional hazards model, the proportional hazards assumption was tested using Schoenfeld residuals (Abeysekera and Sooriyarachchi [&lt;reflink idref=&quot;bib1&quot; id=&quot;ref35&quot;&gt;1&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;In a preliminary analysis, the Schoenfeld residuals method showed that the proportional hazards assumption was not satisfied (&lt;emph&gt;P&lt;/emph&gt; &amp;lt; 0.001), indicating that the difference in the hazard functions of burn injury between the ASD and non-ASD groups was not constant over time. To capture the inconstant hazard functions between groups across AoDs for burn injury, we modeled three different hazard ratios over the entire possible range of AoD for burn injury: (&lt;reflink idref=&quot;bib1&quot; id=&quot;ref36&quot;&gt;1&lt;/reflink&gt;) AoD &amp;lt; 6 years, (&lt;reflink idref=&quot;bib2&quot; id=&quot;ref37&quot;&gt;2&lt;/reflink&gt;) 6 years ≤ AoD ≤ 12 years, and (&lt;reflink idref=&quot;bib3&quot; id=&quot;ref38&quot;&gt;3&lt;/reflink&gt;) AoD &amp;gt;12 years. Furthermore, because the proportional hazards assumption was violated, a time-dependent Cox proportional hazards analysis was conducted to take into account inconstant hazard functions between groups over time. A univariable time-dependent Cox proportional hazards model was used to identify potential risk factors, and a multivariable time-dependent Cox proportional hazards model was employed to determine independent risk factors for the first burn injury. Hazard ratios (HRs) and 95% CIs are reported.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-9&quot;&gt;Results&lt;/hd&gt; &lt;p&gt;&lt;/p&gt; &lt;hd id=&quot;AN0162013108-10&quot;&gt;Sample Characteristics&lt;/hd&gt; &lt;p&gt;Table 1 presents a comparison of demographic data, comorbid diseases, concomitant use of sedatives or anxiolytics, and AoD for burn injury between the ASD and non-ASD groups. The average age was similar between groups, and the average age of children and adolescents with ASD was 13.6 (&#177; 2.8 years). The ASD group was male predominant and comorbid with a greater number of physical and mental diseases, including tic disorders, epilepsy, intellectual disability, and ADHD. A higher percentage of children and adolescents with ASD than without ASD had ever used sedatives or anxiolytics. The cumulative incidence of burn injury was lower in the ASD group than in the non-ASD group. The AoD for burn injury was also lower in the ASD group than in the non-ASD group (5.3 vs. 8.1 years). After stratification based on the AoD for burns, we found that the difference in the cumulative incidence of burn injury between the ASD group and non-ASD groups differed across age groups.&lt;/p&gt; &lt;p&gt;Table 1 Demographics, comorbidities, and use of sedatives or anxiolytics between the ASD and non-ASD groups&lt;/p&gt; &lt;p&gt; &lt;ephtml&gt; &amp;lt;table frame=&quot;hsides&quot; rules=&quot;groups&quot;&amp;gt;&amp;lt;thead&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th&amp;gt;&amp;lt;p&amp;gt;Variable&amp;lt;/p&amp;gt;&amp;lt;/th&amp;gt;&amp;lt;th&amp;gt;&amp;lt;p&amp;gt;ASD&amp;lt;/p&amp;gt;&amp;lt;p&amp;gt;&amp;lt;italic&amp;gt;n&amp;lt;/italic&amp;gt; = 15,844&amp;lt;/p&amp;gt;&amp;lt;/th&amp;gt;&amp;lt;th&amp;gt;&amp;lt;p&amp;gt;Non-ASD&amp;lt;/p&amp;gt;&amp;lt;p&amp;gt;&amp;lt;italic&amp;gt;n&amp;lt;/italic&amp;gt; = 130,860&amp;lt;/p&amp;gt;&amp;lt;/th&amp;gt;&amp;lt;th&amp;gt;&amp;lt;p&amp;gt;&amp;lt;italic&amp;gt;P&amp;lt;/italic&amp;gt; value of &amp;amp;#967;2 or &amp;lt;italic&amp;gt;t&amp;lt;/italic&amp;gt; test&amp;lt;/p&amp;gt;&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/thead&amp;gt;&amp;lt;tbody&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;Age, Mean (SD)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;13.6 (2.8)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;13.7 (3.0)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;0.053&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;Boys, N (%)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;13,162 (83.1)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;64,372 (49.2)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;Tic disorders, N (%)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;847 (5.3)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1330 (1.0)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;Epilepsy, N (%)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1944 (12.3)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;2214 (1.7)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;Intellectual disability, N (%)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;5125 (32.3)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1383 (1.1)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;ADHD, N (%)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;10,931 (69.0)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;6571 (5.0)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;Sedatives/anxiolytics, N (%)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;9108 (57.5)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;12,563 (9.6)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td colspan=&quot;4&quot;&amp;gt;&amp;lt;p&amp;gt;Outcome&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Burns, N (%)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1100 (6.9)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;11,961 (9.1)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Age of diagnosis for burns, Mean (SD)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;5.3 (4.1)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;8.1 (4.5)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td colspan=&quot;4&quot;&amp;gt;&amp;lt;p&amp;gt;Burns in different age groups&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; &amp;amp;#60;6 years&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;472 (3.0)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;8579 (6. 6)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;&amp;amp;#60;0.001&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; 6 years&amp;amp;#8211;12 years&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;469 (3.0)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;2312 (1.8)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td /&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; &amp;amp;#62;12 years&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;159 (1.0)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1066 (0.8)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td /&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/tbody&amp;gt;&amp;lt;/table&amp;gt; &lt;/ephtml&gt; &lt;/p&gt; &lt;p&gt; &lt;emph&gt;ADHD&lt;/emph&gt; attention-deficit/hyperactivity disorder, &lt;emph&gt;ASD&lt;/emph&gt; autism spectrum disorder&lt;/p&gt; &lt;hd id=&quot;AN0162013108-11&quot;&gt;Risk of Burn Injury in Children and Adolescents with ASD&lt;/hd&gt; &lt;p&gt;The Kaplan–Meier survival curves are presented in Fig. 2. This shows differences in the survival functions for burn injury between the ASD and non-ASD groups. Based on the log-rank test, the ASD group generally had a lower risk of burn injury than the non-ASD group (&lt;emph&gt;χ&lt;/emph&gt;2 = 86.36, &lt;emph&gt;P&lt;/emph&gt; &amp;lt; 0.001). Because the Schoenfeld residuals method showed that the proportional hazards assumption was not satisfied (&lt;emph&gt;P&lt;/emph&gt; &amp;lt; 0.001), indicating that the difference in survival functions for burn injury between the ASD and non-ASD groups was not constant over time, we used time-dependent Cox proportional hazards models to address the violation of the proportional hazards assumption, and these results are summarized in Table 2. Univariate analysis indicated that the comparatively lower risk of burn injury in the ASD group was found in the &amp;lt;6 years range of AoD for burn injury, while the ASD group had higher risks of burn injury than the non-ASD group at AoDs ranging from 6 years to 12 years and &amp;gt;12 years. These effects persisted for participants with AoD &amp;lt; 6 years and AoD ranging from 6 years to 12 years after covariates were controlled for but not in those with AoD &amp;gt; 12 years.&lt;/p&gt; &lt;p&gt;Graph: Fig. 2 Survival probabilities for burn injuries between the ASD and non-ASD groups&lt;/p&gt; &lt;p&gt;Table 2 Cox proportional regressions for the risk of first burn injury&lt;/p&gt; &lt;p&gt; &lt;ephtml&gt; &amp;lt;table frame=&quot;hsides&quot; rules=&quot;groups&quot;&amp;gt;&amp;lt;thead&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;th&amp;gt;&amp;lt;p&amp;gt;Variable&amp;lt;/p&amp;gt;&amp;lt;/th&amp;gt;&amp;lt;th&amp;gt;&amp;lt;p&amp;gt;Crude HR&amp;lt;/p&amp;gt;&amp;lt;p&amp;gt;(95% confidence interval)&amp;lt;/p&amp;gt;&amp;lt;/th&amp;gt;&amp;lt;th&amp;gt;&amp;lt;p&amp;gt;Adjusted HR&amp;lt;/p&amp;gt;&amp;lt;p&amp;gt;(95% confidence interval)&amp;lt;/p&amp;gt;&amp;lt;/th&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/thead&amp;gt;&amp;lt;tbody&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td colspan=&quot;3&quot;&amp;gt;&amp;lt;p&amp;gt;ASD&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; AoD &amp;amp;#60; 6 years&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;0.44 (0.40&amp;amp;#8211;0.49)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;0.34 (0.30&amp;amp;#8211;0.38)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; 6 years &amp;amp;#8804; AoD &amp;amp;#60; 12 years&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.61 (1.46&amp;amp;#8211;1.78)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.22 (1.09&amp;amp;#8211;1.36)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; AoD &amp;amp;#8805; 12 years&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.39 (1.17&amp;amp;#8211;1.64)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.01 (0.84&amp;amp;#8211;1.20)&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Age&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;0.91 (0.91&amp;amp;#8211;0.92)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;0.91 (0.91&amp;amp;#8211;0.92)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Boy&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.17 (1.13&amp;amp;#8211;1.21)**&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.21 (1.17&amp;amp;#8211;1.26)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; ADHD&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.06 (1.01&amp;amp;#8211;1.11)*&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.31 (1.23&amp;amp;#8211;1.40)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Tic disorders&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.17 (1.03&amp;amp;#8211;1.33)**&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.20 (1.05&amp;amp;#8211;1.37)**&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Epilepsy&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.34 (1.23&amp;amp;#8211;1.47)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.49 (1.36&amp;amp;#8211;1.64)**&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Intellectual disability&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.19 (1.10&amp;amp;#8211;1.28)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;1.61 (1.47&amp;amp;#8211;1.76)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;tr&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt; Sedatives/anxiolytics&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;0.63 (0.59&amp;amp;#8211;0.66)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;td&amp;gt;&amp;lt;p&amp;gt;0.66 (0.62&amp;amp;#8211;0.70)***&amp;lt;/p&amp;gt;&amp;lt;/td&amp;gt;&amp;lt;/tr&amp;gt;&amp;lt;/tbody&amp;gt;&amp;lt;/table&amp;gt; &lt;/ephtml&gt; &lt;/p&gt; &lt;p&gt; &lt;emph&gt;ADHD&lt;/emph&gt; attention-deficit/hyperactivity disorder, &lt;emph&gt;AoD&lt;/emph&gt; age of diagnosis, &lt;emph&gt;ASD&lt;/emph&gt; autism spectrum disorder, &lt;emph&gt;HR&lt;/emph&gt; hazard ratio *&lt;emph&gt;p&lt;/emph&gt; &amp;lt; 0.05, **&lt;emph&gt;p&lt;/emph&gt; &amp;lt; 0.01, ***&lt;emph&gt;p&lt;/emph&gt; &amp;lt; 0.001&lt;/p&gt; &lt;hd id=&quot;AN0162013108-12&quot;&gt;Other Potential Risk Factors and Protective Factors&lt;/hd&gt; &lt;p&gt;The adjusted Cox proportional hazards model revealed that being male and having ADHD, tic disorders, epilepsy, and intellectual disability were risk factors for burn injury. In contrast, younger age and use of sedatives or anxiolytics were associated with reduced risks of burn injury.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-13&quot;&gt;Discussion&lt;/hd&gt; &lt;p&gt;To our knowledge, this is the first population-based study to specifically explore burn injury risk in the pediatric population with ASD. The unadjusted outcomes indicated a lower risk of burn injury in children and adolescents with ASD than in the population without ASD. After adjustment for confounding factors, we found that the hazard ratios differed based on AoD: a lower risk was found in the ASD group with an AoD &amp;lt; 6 years, a higher risk was found in the ASD group with an AoD ranging from 6 years to 12 years, and no difference was found in the ASD group with an AoD &amp;gt; 12 years. This finding may partly account for the inconsistent results regarding ASD and burn injury in the current literature.&lt;/p&gt; &lt;p&gt;The first key finding of our study was the substantially lower burn injury risk in the pediatric population with ASD. However, the decreased risk for burn injury did not occur in the two older age groups, and the mean AoD of burn injury was lower in the ASD group than in the non-ASD group. These findings may suggest that the influencing factors of the relative risk of burn injury in ASD may change with age and are related to development stage. Children with ASD tend to play alone, and they are less likely to seek the company of adults and engage in less imitation than typical children, especially the children that are diagnosed with ASD later (Martinez-Pedraza Fde and Carter [&lt;reflink idref=&quot;bib30&quot; id=&quot;ref39&quot;&gt;30&lt;/reflink&gt;]). For these reasons, children with ASD may be less likely to follow adults in the kitchen or bathroom, consequently decreasing the risk of being scalded by hot soup, food, water, or steam (Palmieri et al. [&lt;reflink idref=&quot;bib35&quot; id=&quot;ref40&quot;&gt;35&lt;/reflink&gt;]; Atiyeh et al. [&lt;reflink idref=&quot;bib4&quot; id=&quot;ref41&quot;&gt;4&lt;/reflink&gt;]). Moreover, children with ASD display behaviors and play in a considerably different manner than those with ADHD. They prefer repetitive sensory stimulation and stereotyped motor behaviors and concentrate on restricted interests for extended periods (Jacques et al. [&lt;reflink idref=&quot;bib17&quot; id=&quot;ref42&quot;&gt;17&lt;/reflink&gt;]). Consequently, children with ASD may not have an additional burn risk resulting from impulsivity, inattentiveness, and risky behaviors, as reported in children with ADHD or ADHD symptoms (Thomas et al. [&lt;reflink idref=&quot;bib42&quot; id=&quot;ref43&quot;&gt;42&lt;/reflink&gt;]; Badger et al. [&lt;reflink idref=&quot;bib5&quot; id=&quot;ref44&quot;&gt;5&lt;/reflink&gt;]; Fritz and Butz [&lt;reflink idref=&quot;bib15&quot; id=&quot;ref45&quot;&gt;15&lt;/reflink&gt;]; Emond et al. [&lt;reflink idref=&quot;bib13&quot; id=&quot;ref46&quot;&gt;13&lt;/reflink&gt;]). However, children with comorbid ASD and ADHD may warrant additional attention for probable increased burn risk (DiGuiseppi et al. [&lt;reflink idref=&quot;bib10&quot; id=&quot;ref47&quot;&gt;10&lt;/reflink&gt;]). Previous studies (Edelman [&lt;reflink idref=&quot;bib12&quot; id=&quot;ref48&quot;&gt;12&lt;/reflink&gt;]; Peck [&lt;reflink idref=&quot;bib36&quot; id=&quot;ref49&quot;&gt;36&lt;/reflink&gt;]; Laitakari et al. [&lt;reflink idref=&quot;bib23&quot; id=&quot;ref50&quot;&gt;23&lt;/reflink&gt;]) have surveyed and indicated several influencing factors for pediatric burn injury risk, including gender, developmental stage, ethnicity, socioeconomic status, family structure, maternal education and age. Children with ASD have features that may become risk factors for burns, including male predominance (Lai et al. [&lt;reflink idref=&quot;bib22&quot; id=&quot;ref51&quot;&gt;22&lt;/reflink&gt;]), parental psychopathology (Schnabel et al. [&lt;reflink idref=&quot;bib38&quot; id=&quot;ref52&quot;&gt;38&lt;/reflink&gt;]), and sensorimotor difficulties (Mosconi and Sweeney [&lt;reflink idref=&quot;bib32&quot; id=&quot;ref53&quot;&gt;32&lt;/reflink&gt;]). This study also revealed distinct hazard ratios for burns over the three age periods between those with and without ASD. This finding may correspond to the inconsistent results across previous studies and warrants more research to survey age effects in relation to burn risk in autism.&lt;/p&gt; &lt;p&gt;Dangerous fire play and fire-setting behavior have also been considerable causes of pediatric burn injury (Fritz and Butz [&lt;reflink idref=&quot;bib15&quot; id=&quot;ref54&quot;&gt;15&lt;/reflink&gt;]; Ying and Ho [&lt;reflink idref=&quot;bib44&quot; id=&quot;ref55&quot;&gt;44&lt;/reflink&gt;]). Some studies have investigated the psychopathology and characteristics of youths with fire interest. Dadds et al. examined children aged 4–9 years and found that fire-setting behavior was associated with antisocial behavior, hyperactivity, conduct problems and a thrill-seeking temperament (Dadds and Fraser [&lt;reflink idref=&quot;bib9&quot; id=&quot;ref56&quot;&gt;9&lt;/reflink&gt;]). Another recent study that surveyed youths with fire-setting behaviors similarly reported that those individuals had an increased risk of conduct, attention, and hyperactivity difficulties (Lambie and Krynen [&lt;reflink idref=&quot;bib24&quot; id=&quot;ref57&quot;&gt;24&lt;/reflink&gt;]). Children with ASD have a tendency toward harm avoidance in contrast to the novelty-seeking characteristics of children with ADHD (Kerekes et al. [&lt;reflink idref=&quot;bib20&quot; id=&quot;ref58&quot;&gt;20&lt;/reflink&gt;]). However, there is a lack of studies exploring attitudes toward fire in individuals with ASD. Future research should clarify whether individuals with ASD have a more problematic interest in or marked fear of fire than typical children.&lt;/p&gt; &lt;p&gt;The average ages of onset for burn injury in the ASD and non-ASD groups were both young. It is worth noting that very young children have a higher risk for the occurrence and poorer prognosis of burn injury (Thombs et al. [&lt;reflink idref=&quot;bib43&quot; id=&quot;ref59&quot;&gt;43&lt;/reflink&gt;]; D&#39;Souza et al. [&lt;reflink idref=&quot;bib11&quot; id=&quot;ref60&quot;&gt;11&lt;/reflink&gt;]; Lin et al. [&lt;reflink idref=&quot;bib27&quot; id=&quot;ref61&quot;&gt;27&lt;/reflink&gt;]). Young children constitute more than half of the pediatric burn cases, and the risk of burns generally decreased with age (D&#39;Souza et al. [&lt;reflink idref=&quot;bib11&quot; id=&quot;ref62&quot;&gt;11&lt;/reflink&gt;]; Lin et al. [&lt;reflink idref=&quot;bib27&quot; id=&quot;ref63&quot;&gt;27&lt;/reflink&gt;]). Because children under 5 years of age are at a higher risk for burn injury and the effects of burn injury, several studies have investigated risk factors and prevention methods in this age group. Most burn injuries in this age group occur at home, and crucial, modifiable risk factors include keeping hot liquids (e.g., water, soup) away from children (Stewart et al. [&lt;reflink idref=&quot;bib41&quot; id=&quot;ref64&quot;&gt;41&lt;/reflink&gt;]; Lowell et al. [&lt;reflink idref=&quot;bib28&quot; id=&quot;ref65&quot;&gt;28&lt;/reflink&gt;]), checking bath water temperature, and teaching children about the dangers of hot objects liquids and about safety rules in the kitchen and bathroom (Stewart et al. [&lt;reflink idref=&quot;bib41&quot; id=&quot;ref66&quot;&gt;41&lt;/reflink&gt;]; Shields et al. [&lt;reflink idref=&quot;bib40&quot; id=&quot;ref67&quot;&gt;40&lt;/reflink&gt;]). Water heater manufacturers have also cooperated by lowering the water temperature preset point (Shields et al. [&lt;reflink idref=&quot;bib39&quot; id=&quot;ref68&quot;&gt;39&lt;/reflink&gt;]). These key recommendations can also be applied for children with ASD. However, due to a paucity of studies on the etiology of burns in children with ASD, specific preventive suggestions for the pediatric population with ASD are still lacking, and more research is warranted.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-14&quot;&gt;Strengths and Limitations&lt;/hd&gt; &lt;p&gt;This study has several methodological strengths. First, it was based on a national population database. This methodological advantage eliminated selection bias and recall bias. The control group (i.e., individuals without ASD), formed from our population database, was large and representative. Moreover, the proportional hazard assumption and the major comorbid diseases and concomitant medications were taken into consideration or adjusted for as confounding factors. We also analyzed the AoD of burn injury to provide additional information for future pediatric injury prevention programs. There are some limitations to our study. First, no validation study for ASD was conducted with the NHRI database. However, this might have little impact on our results because the differential diagnosis of ASD is not difficult based on the significant features of the behavioral symptoms. This notion was also supported by a validation study for ASD, wherein 94% of diagnoses of autism in children in the Danish register datasets were confirmed (Lauritsen et al. [&lt;reflink idref=&quot;bib25&quot; id=&quot;ref69&quot;&gt;25&lt;/reflink&gt;]). In addition, information regarding family environment and social class level, such as parental stress, parental psychiatric diseases, and education level, was not available in this study. It has been observed that after adjustments for family environment and social class level, a higher risk of burn injury was still found in individuals with ASD than in those without ASD (Jain et al. [&lt;reflink idref=&quot;bib18&quot; id=&quot;ref70&quot;&gt;18&lt;/reflink&gt;]; Lee et al. [&lt;reflink idref=&quot;bib26&quot; id=&quot;ref71&quot;&gt;26&lt;/reflink&gt;]), despite a slight decrease in its magnitude (i.e., hazard ratio or odds ratio). Moreover, the extent and severity of burn injury and the prognosis of the injury were not provided in the database used.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-15&quot;&gt;Conclusions&lt;/hd&gt; &lt;p&gt;The present study revealed that the pediatric population with ASD had a lower risk of burn injury. More studies are warranted to survey the etiology and characteristics of burn injury in this population and age-specific interventions for burn injury in the ASD population.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-16&quot;&gt;Acknowledgments&lt;/hd&gt; &lt;p&gt;This work was supported by grants from the Chang Gung Memorial Hospital (CLRPG6G0042, CLRPG6G0043). The present study was based on the National Health Insurance Research Database provided by the Central Bureau of National Health Insurance, the Department of Health, and managed by the National Health Research Institutes.&lt;/p&gt; &lt;hd id=&quot;AN0162013108-17&quot;&gt;Publisher&#39;s Note&lt;/hd&gt; &lt;p&gt;Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.&lt;/p&gt; &lt;ref id=&quot;AN0162013108-18&quot;&gt; &lt;title&gt; References &lt;/title&gt; &lt;blist&gt; &lt;bibl id=&quot;bib1&quot; idref=&quot;ref35&quot; type=&quot;bt&quot;&gt;1&lt;/bibl&gt; &lt;bibtext&gt; Abeysekera W, Sooriyarachchi R. Use of Schoenfeld&#39;s global test to test the proportional hazards assumption in the cox proportional hazards model: An application to a clinical study. 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  Label: Title
  Group: Ti
  Data: Lower Risk of Burn Injury in Children and Adolescents with Autism Spectrum Disorder: A Nationwide Population-Based Study
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: &lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Chan%2C+Hsiang-Lin%22&quot;&gt;Chan, Hsiang-Lin&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Hsieh%2C+Yi-Hsuan%22&quot;&gt;Hsieh, Yi-Hsuan&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Lin%2C+Chiao-Fan%22&quot;&gt;Lin, Chiao-Fan&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Liang%2C+Hsin-Yi%22&quot;&gt;Liang, Hsin-Yi&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Lee%2C+Su-Shin%22&quot;&gt;Lee, Su-Shin&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Weng%2C+Jun-Cheng%22&quot;&gt;Weng, Jun-Cheng&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Lee%2C+Min-Jing%22&quot;&gt;Lee, Min-Jing&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Chen%2C+Yi-Lung%22&quot;&gt;Chen, Yi-Lung&lt;/searchLink&gt; (ORCID &lt;externalLink term=&quot;http://orcid.org/0000-0003-2934-5814&quot;&gt;0000-0003-2934-5814&lt;/externalLink&gt;)&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Chen%2C+Vincent+Chin-Hung%22&quot;&gt;Chen, Vincent Chin-Hung&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Gossop%2C+Michael%22&quot;&gt;Gossop, Michael&lt;/searchLink&gt;
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  Label: Source
  Group: Src
  Data: &lt;searchLink fieldCode=&quot;SO&quot; term=&quot;%22Journal+of+Autism+and+Developmental+Disorders%22&quot;&gt;&lt;i&gt;Journal of Autism and Developmental Disorders&lt;/i&gt;&lt;/searchLink&gt;. Feb 2023 53(2):648-655.
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  Label: Availability
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: Y
– Name: Pages
  Label: Page Count
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  Data: 8
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2023
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles&lt;br /&gt;Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: &lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Fire+Protection%22&quot;&gt;Fire Protection&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Injuries%22&quot;&gt;Injuries&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Autism+Spectrum+Disorders%22&quot;&gt;Autism Spectrum Disorders&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Children%22&quot;&gt;Children&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Adolescents%22&quot;&gt;Adolescents&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Foreign+Countries%22&quot;&gt;Foreign Countries&lt;/searchLink&gt;
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: &lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Taiwan%22&quot;&gt;Taiwan&lt;/searchLink&gt;
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10803-020-04859-9
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0162-3257&lt;br /&gt;1573-3432
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Little research has examined burn injury in the pediatric population with autism spectrum disorder (ASD). We used data from Taiwan&#39;s National Health Insurance Research Database to identify 15,844 participants aged &lt;18 years with ASD and 130,860 participants without ASD. Our results revealed that the hazard ratios differed across three age ranges. The ASD group had a lower risk of burn injury than the non-ASD group when they were less than 6 years of age, a higher risk from 6 years to 12 years of age, and no difference when they were older than 12 years of age. More research is required to study the characteristics and causes of burn injury in the pediatric population with ASD.
– Name: AbstractInfo
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2023
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1368740
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1368740
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    Identifiers:
      – Type: doi
        Value: 10.1007/s10803-020-04859-9
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 8
        StartPage: 648
    Subjects:
      – SubjectFull: Fire Protection
        Type: general
      – SubjectFull: Injuries
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Taiwan
        Type: general
    Titles:
      – TitleFull: Lower Risk of Burn Injury in Children and Adolescents with Autism Spectrum Disorder: A Nationwide Population-Based Study
        Type: main
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            NameFull: Chan, Hsiang-Lin
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            NameFull: Hsieh, Yi-Hsuan
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            NameFull: Chen, Vincent Chin-Hung
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            NameFull: Gossop, Michael
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          Dates:
            – D: 01
              M: 02
              Type: published
              Y: 2023
          Identifiers:
            – Type: issn-print
              Value: 0162-3257
            – Type: issn-electronic
              Value: 1573-3432
          Numbering:
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              Value: 53
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            – TitleFull: Journal of Autism and Developmental Disorders
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