The Crisis of Transition: Addressing Mortality in Neurodevelopmental Disabilities
For decades, clinical attention for neurodevelopmental disabilities (NDDs) such as autism spectrum disorder (ASD), intellectual disability (ID), and cerebral palsy (CP) has been heavily weighted toward early diagnosis and pediatric intervention. However, as medical advancements have improved survival rates into adulthood, a new clinical challenge has emerged: the ‘cliff’ of adult care. A recent comprehensive study published in JAMA Pediatrics by Shaw et al. provides a sobering assessment of mortality among youth and young adults with these conditions, offering a critical roadmap for clinicians and health policy experts to address persistent health disparities.
Historically, mortality data for NDD populations in the United States have been fragmented. The lack of robust, population-based longitudinal data has made it difficult to quantify the specific risks faced by these individuals as they transition from the structured environment of pediatric care to the often-fragmented adult healthcare system. The findings from this latest surveillance study underscore a significant and multifaceted mortality gap that requires immediate clinical and systemic attention.
Methodological Framework: The ADDM Network Study
The research utilized data from the Centers for Disease Control and Prevention’s (CDC) Autism and Developmental Disabilities Monitoring (ADDM) Network. This active population-based surveillance system identified 32,787 individuals across nine US sites who met case definitions for ASD, ID, and/or CP at age 8. The cohort was tracked biennially from 2000 through 2016 and linked to death certificates through 2021.
By comparing this cohort to general population data from the National Vital Statistics System, researchers were able to calculate hazard ratios (HR) for mortality and categorize causes of death using ICD-10 codes. This methodology provides one of the most rigorous looks at mortality in this population to date, particularly because it relies on active surveillance rather than just medical records or self-reporting.
Key Findings: Quantifying the Risk
The results of the study reveal a stark disparity in survival outcomes for individuals with NDDs compared to the general population. The hazard ratios for death were significantly elevated across all three primary categories:
Cerebral Palsy: The Highest Risk Profile
Individuals with Cerebral Palsy faced the most dramatic increase in mortality, with a hazard ratio of 9.62 (95% CI, 8.06-11.48). This nearly ten-fold increase in mortality risk underscores the complex medical needs often associated with CP, including respiratory complications and neurological comorbidities. The study found that diseases of the nervous system (ICD-10 codes G00-G99) were the most common underlying cause of death for this group.
Intellectual Disability and the Impact of Co-occurring Conditions
The ID case group also showed a substantial increase in mortality, with a hazard ratio of 4.35 (95% CI, 3.87-4.88). Like the CP group, the most frequent causes of death were related to nervous system diseases. This suggests that the physiological impact of ID—often associated with genetic syndromes or early brain injury—continues to play a major role in health outcomes through young adulthood.
Autism Spectrum Disorder: A Nuanced Risk Landscape
For the ASD group, the overall hazard ratio was 1.35 (95% CI, 1.15-1.59). While lower than the risks for CP and ID, it still represents a statistically significant increase over the general population. However, the data revealed a crucial intersectional risk: the mortality for ASD was significantly higher only for females with co-occurring intellectual disability (HR, 5.04; 95% CI, 3.21-7.91). This finding suggests that the combination of female sex and co-occurring cognitive impairment represents a particularly vulnerable demographic within the autism community.
Primary Causes of Death and Clinical Implications
Understanding why these individuals are dying is as important as knowing the rate at which they die. The study highlighted clear differences in the distribution of ICD-10 causes of death across the groups.
In the general population and the ASD group, the most common underlying causes of death were external causes of morbidity and mortality (V01-Y98), which include accidents, injuries, and self-harm. Interestingly, the study noted that mortality from external causes was not elevated for the ID and CP groups compared to the general population. Instead, their risks were concentrated in systemic and neurological diseases.
For clinicians, this indicates that preventive strategies must be tailored to the specific disability. For individuals with ASD, safety, injury prevention, and mental health support are paramount. For those with CP and ID, the focus must remain on managing chronic neurological and systemic health issues to prevent premature mortality.
The Problem of the ‘Invisible’ Disability on Death Certificates
One of the most significant findings of this research is the failure of death certificates to accurately reflect NDD diagnoses. The study found that only 11% of individuals with ASD, 1% of those with ID, and 49% of those with CP had their respective disability listed as a code on their death certificate.
This discrepancy has profound implications for public health. If death certificates do not record these conditions, then traditional vital statistics will consistently underestimate the mortality burden associated with NDDs. This leads to a lack of visibility in health policy and a potential misallocation of resources. The researchers emphasize that NDDs should be recognized as important contributors to health status, even if they are not the immediate underlying cause of death.
Expert Commentary: Bridging the Gap in Adult Care
The transition from pediatric to adult healthcare is often cited as a period of extreme vulnerability for patients with NDDs. Pediatricians provide a medical home that is specialized in developmental needs, but adult primary care physicians often feel under-equipped to manage the complexities of ASD, ID, or CP.
The data from Shaw et al. suggest that this transition is not merely an administrative challenge but a matter of life and death. The elevated hazard ratios, particularly for those with co-occurring conditions, call for a more integrated approach to adult medicine. This includes:
1. Enhanced training for adult primary care providers in neurodevelopmental health.
2. Standardized protocols for transitioning patients with complex NDDs.
3. Increased focus on preventive screenings that are accessible to those with cognitive or physical impairments.
4. Improved documentation practices to ensure that NDDs are recognized in medical records and legal documents as significant health factors.
Study Limitations and Future Research
While the ADDM Network provides a strong foundation, the study is limited by its geographic scope (nine US sites) and the age of the cohort. As these individuals continue to age into their 30s, 40s, and beyond, the mortality profile may shift again. Future research should focus on the specific social determinants of health—such as access to specialized housing, employment support, and long-term care—that may influence these mortality rates.
Additionally, the study’s reliance on death certificate linkage, while standard, is limited by the very under-reporting the authors identified. More integrated data systems that link health insurance claims, clinical records, and social service data may provide a more granular view of the factors leading to mortality.
Conclusion
The findings of this study serve as a wake-up call for the medical community. The increased mortality observed in young adults with ASD, ID, and CP is a clear indicator of unmet health needs and systemic disparities. By identifying the specific risks—such as the high hazard ratios for females with ASD and ID, and the pervasive under-reporting on death certificates—clinicians and policy makers can begin to develop the targeted interventions necessary to close the mortality gap. Ensuring that individuals with neurodevelopmental disabilities receive high-quality, specialized care throughout their lifespan is not just a clinical goal; it is a fundamental requirement for health equity.
References
1. Shaw KA, McArthur D, Bilder DA, et al. Mortality Among Youth and Young Adults With Autism Spectrum Disorder, Intellectual Disability, or Cerebral Palsy. JAMA Pediatr. Published online February 9, 2026. doi:10.1001/jamapediatrics.2025.6120.
2. Centers for Disease Control and Prevention (CDC). Autism and Developmental Disabilities Monitoring (ADDM) Network.
3. National Vital Statistics System, National Center for Health Statistics (NCHS).
