Timing of the Diagnosis of Attention-

Deficit/Hyperactivity Disorder and

Autism Spectrum Disorder
Amir Miodovnik, MD, MPHa,b, Elizabeth Harstad, MD, MPHa,b, Georgios Sideridis, PhDa,b,c, Noelle Huntington, PhDa,b

abstract BACKGROUND AND OBJECTIVE: Symptoms of inattention, hyperactivity, and impulsivity are core features of
attention-deficit/hyperactivity disorder (ADHD). However, children with autism spectrum disorder
(ASD) often present with similar symptoms and may receive a diagnosis of ADHD first. We
investigated the relationship between the timing of ADHD diagnosis in children with ASD and the age
at ASD diagnosis.
METHODS:Data were drawn from the 2011–2012 National Survey of Children’s Health, which
asked parents to provide the age(s) at which their child received a diagnosis of ADHD and/or
ASD. Using weighted prevalence estimates, we examined the association between a previous
diagnosis of ADHD and the age at ASD diagnosis, while controlling for factors known to
influence the timing of ASD diagnosis.
Our study consisted of 1496 children with a current diagnosis of ASD as reported by
RESULTS:
parents of children ages 2 to 17 years. Approximately 20% of these children had initially been
diagnosed with ADHD. Children diagnosed with ADHD before ASD were diagnosed with ASD
∼3 years (95% confidence interval 2.3–3.5) after children in whom ADHD was diagnosed at
the same time or after ASD. The children with ADHD diagnosed first were nearly 30 times
more likely to receive their ASD diagnosis after age 6 (95% confidence interval 11.2–77.8).
The delay in ASD diagnosis was consistent across childhood and independent of ASD severity.
CONCLUSION: To
avoid potential delays in ASD diagnosis, clinicians should consider ASD in young
children presenting with ADHD symptoms.

WHAT’S KNOWN ON THIS SUBJECT: Many studies
have suggested that autism spectrum disorder (ASD)
and attention-deficit/hyperactivity disorder (ADHD)
are commonly co-occuring neurodevelopmental
conditions.
WHAT THIS STUDY ADDS: In children with
co-occurring ASD and ADHD, an initial ADHD
diagnosis may be associated with delayed
ASD diagnosis and a higher likelihood of ASD
diagnosis older than 6 years of age. Clinicians
should consider ASD when evaluating young
children presenting with ADHD symptoms.
a
Division of Developmental Medicine, and cClinical Research Center, Boston Children’s Hospital, Boston,
Massachusetts; and bHarvard Medical School, Boston, Massachusetts
Dr Miodovnik conceptualized and designed the study, conducted the analyses, drafted the initial manuscript,
and reviewed and revised the manuscript; Dr Harstad reviewed and revised the manuscript; Dr Sideridis
critically reviewed the analyses; Dr Huntington reviewed all analyses completed by Dr Miodovnik and
critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2015-1502
DOI: 10.1542/peds.2015-1502
Accepted for publication Jul 6, 2015
Address correspondence to Amir Miodovnik, MD, MPH, Division of Developmental Medicine,
1 Autumn St, Boston, MA 02215. E-mail: amir.miodovnik@childrens.harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2015 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to
this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Dr Harstad has been the recipient of grants from SynapDx. The
other authors have indicated they have no potential conflicts of interest to disclose.

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ARTICLE PEDIATRICS Volume 136, number 4, October 2015
Although autism spectrum disorder
(ASD) and attention-deficit/
hyperactivity disorder (ADHD) are
unique neurobiological conditions,
they have been shown to share
genetic factors1–3 and neural
pathways.4–6 They also exhibit many
overlapping phenotypic features,
including attentional and social
vulnerabilities7–9 and externalizing
symptoms, such as impulsivity and
hyperactivity.10,11 In addition, trend
analyses using data from the
2011–2012 National Survey of
Children’s Health (NSCH) reported
dramatic increases in the prevalence
of both ASD and ADHD. The most
recent estimates of parent-reported
diagnosis by a health care provider
were 2% for ASD in children 6 to 17
years old12 and 11% for ADHD in
children 4 to 17 years old.13
ASD can be reliably diagnosed in
children as young as 24 months14,15;
however, the median age at first ASD
diagnosis remains older than 4
years.16 Pringle et al17 found that
40% of 6- to 17-year-old children
with special health care needs and
ASD were aged 6 years and older
when first identified as having ASD.
This is well beyond the age when
signs and symptoms should clearly be
notable and when behavioral
therapies appear to be most
effective.18–20
Numerous studies have identified
family and child factors associated
with disparities in the diagnosis of
ASD.21 Minority background, lower
level of parent education, and
disadvantaged socioeconomic
circumstances have all been
correlated with increased age of
diagnosis.22,23 Levy et al24 identified
an association between later
diagnosis of ASD and the presence of
co-occurring developmental,
psychiatric, and neurologic disorders.
Similarly, 51% of children in Iceland
diagnosed with ASD after age 6 had
a previous non-ASD developmental
diagnosis.25 A more recent study in
Israel focused on children who
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PEDIATRICS Volume 136, number 4, October 2015
received a diagnosis of ASD at or
after age 6 despite having undergone
a comprehensive multidisciplinary
assessment before age 6. Almost half
of the sample had demonstrated
ADHD features at the initial
assessment. The authors suggest
several reasons for why ASD
diagnoses may have been missed at
younger ages, including social and
pragmatic deficits that gradually
emerge as social demands increase
with age.26
A larger population-based cohort in
Nova Scotia, Canada, used
administrative health databases to
obtain the age at ASD diagnosis for
884 children.27 In adjusted models,
the 3 features related to age of
diagnosis were maternal age, county
of residence, and co-occurring ADHD.
An ASD diagnosis occurred 1.29 years
later (95% confidence interval [CI]
0.93–1.64) if a child had a comorbid
ADHD diagnosis compared with
a child without ADHD. Interestingly,
in almost 60% of these cases, an
ADHD diagnosis had been
documented some time before the
ASD diagnosis.
Although these studies suggest that
symptoms of ADHD may overshadow
or mask the symptoms of ASD, none
have examined the relationship
between the age at ADHD diagnosis
and the age at ASD diagnosis. We
hypothesized that a diagnosis of
ADHD before ASD would be
associated with delayed ASD
diagnosis compared with children
who received an ADHD diagnosis at
the same time or after an ASD
diagnosis or children with ASD only.
METHODS
Data for this study were drawn from
the 2011–2012 NSCH public-use data
file. The NSCH is directed and funded
by the Maternal and Child Health
Bureau of the Health Resources and
Services Administration and is
administered by the National Center
for Health Statistics. The 2011–2012
NSCH used a multistage cluster
design based on a random
digit–dialed sample of households
with children younger than 18 years
of age selected from each of the 50
states and the District of Columbia.
The respondent was a parent or
guardian in the household who was
knowledgeable about the child’s
health. The overall response rate for
2011–2012 was 23%. A total of 95
677 interviews were completed
from February 2011 through June
2012.12 Information about parent-
reported ASD diagnosis was
obtained for 85 556 children ages 2
to 17 years. For more information
about NSCH, including its sample
design, data collection procedures,
and questionnaire content, visit
http://www.cdc.gov/nchs/slaits/
nsch.htm.
Study Sample
Children classified as having ASD
were those for whom a parent
provided valid responses to the
following questions: “Has a doctor or
other health care provider ever told
you that [study child] had autism,
Asperger disorder, pervasive
developmental disorder, or other
autism spectrum disorder?” “How old
was [study child] when you were first
told by a doctor or other health care
provider that [he/she] had autism or
ASD?” and “Does [study child]
currently have autism or ASD?” To
obtain the temporal order between
ASD and ADHD diagnoses, a parent
had to provide a valid response to the
question: “How old was [study
child] when you were first told by
a doctor or other health care
provider that [he/she] had ADD or
ADHD?” Based on the responses
to these questions, we defined a
3-level variable: (1) ADHD before
ASD, (2) ADHD same/after ASD, and
(3) ASD only. Omissions to these
variables, including “refusal” or
“don’t know” responses, or no
current ASD diagnosis were
excluded. We set the lower limit of
diagnosis for ASD at 2 years 14,15
e831
and for ADHD at 3 years28–30 based
on previous literature.
Study Variables
All sociodemographic variables were
acquired by parent report and
included child gender, race (white,
black, other), ethnicity (Hispanic,
non-Hispanic), mother’s education
(high school diploma or less, more
than high school diploma), parent-
reported ASD severity (mild,
moderate, severe), and household
income (#200% of the federal
poverty level [FPL], 201%–400%
FPL, .400% FPL). Co-occurring
conditions of interest included
parent-reported developmental delay,
speech problems, and intellectual
disability. All study covariates have
been significantly associated with
variations in the timing of ASD
diagnosis in previous studies.21 We
also included child’s age at the time
the survey was completed to account
for any secular trends in diagnostic
patterns for ASD or ADHD.
Analytic Methods
All statistical data analyses were
performed using SPSS version 22.0
(IBM SPSS Statistics, IBM
Corporation, Chicago, IL) with SPSS
Complex Samples, which accounted
for the complex survey design of
NSCH, including clustering of children
within households, stratification of
households within states, and
unequal sampling weights. Using
sample weights to calculate
prevalence estimates and SEs better
represents the noninstitutionalized
population of the United States. A .05
level of significance was used in the
analyses. In comparing weighted
proportions, significance was based
on the adjusted F statistic, a variant of
the second-order Rao Scott adjusted
x2 statistic used for analyses with
sample weights. We used the General
Linear Model procedure within the
Complex Samples Module to examine
the associations between the age at
ASD diagnosis and the 3 study groups
while controlling for other
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e832
independent variables. Adjusted odds
ratios were obtained from
multivariate logistic regression
analysis using age at ASD diagnosis
dichotomized at 6 years of age as the
binary dependent variable. The
Boston Children’s Hospital
Institutional Review Board exempted
this study as nonhuman subject
research.
RESULTS
The final sample included 1496 study
children with a current ASD
diagnosis. For 705 (42.9%) of these
children, the parent or caregiver
indicated that the child had also
received an ADHD diagnosis and
provided the age at ADHD diagnosis.
Of the children with co-occurring ASD
and ADHD, 313 (44.5%) comprised
the ADHD before ASD group. The
group with ADHD before ASD
contained a significantly smaller
proportion of children with speech
problems than the other 2 subgroups
(adjusted F[1.88, 2729] = 4.91, P =
.009). Overall, children with ADHD
before ASD were ∼4 years older when
they received their ASD diagnosis
(F[2, 1449] = 51.51, P , .001) and
81% were diagnosed after age 6
(adjusted F[1.79, 2595] = 35.15, P ,
.001). The 3 groups were similar in
the distribution of other demographic
characteristics. All of the factors listed
in Table 1 were included in our final
models because a review of the
literature had indicated they were
significantly associated with the
timing of ASD diagnosis (Table 1).21
Across study groups, the presence of
speech problems was associated with
an ASD diagnosis occurring 1.2 years
earlier, whereas children with an
intellectual disability were diagnosed
with ASD 0.6 years earlier. Mild to
moderate autism severity was
associated with later diagnosis
compared with those with severe
ASD.
Controlling for all covariates, ADHD
before ASD was associated with a
2.9-year delay (b = 2.87 t[1211] = 9.64,
P , .001) in the age at ASD diagnosis
when compared with children with
ASD only. The results of the
regression indicated that our full
models explained 53% of the
variance (R2 = 0.53, F[2, 1210] =
59.51, P , .001). In contrast, the age
at ASD diagnosis for the group with
ADHD same/after ASD was not
significantly different than it was for
children with ASD only. We re-ran the
same model shifting which group
served as the reference to directly
compare the 2 groups with comorbid
ASD and ADHD. We found that ADHD
before ASD was associated with a
3.2-year delay (b = 3.18, t[1211] = 9.86,
P , .001) in ASD diagnosis compared
with ADHD same/after ASD (Table 2).
Figure 1 illustrates how the gap in
age at ASD diagnosis between the 2
groups with ADHD remains fairly
constant across early childhood and
into adolescence.
Looking at the probability of
receiving an ASD diagnosis after
6 years of age, children with ADHD
before ASD were 16.7 times more
likely to be diagnosed with ASD after
6 years of age (t[1211] = 6.38, P ,
.001) compared with children with
ASD only and 29.5 (95% CI
11.2–77.8) times more likely
compared with children with ADHD
same/after ASD (t[1211] = 6.86, P ,
.001) (Table 2). Children with mild
and moderate autism were also more
likely to be diagnosed after 6 years
compared with severe presentations.
Notably, whereas children with
milder cases of ASD were more likely
to be diagnosed after 6 years of age,
the disparity in age of ASD diagnosis
for the ADHD before ASD group was
maintained across all severity levels
(Fig 2).
DISCUSSION
The American Academy of Pediatrics
(AAP) guidelines endorse universal
screening for ASD at 18 and 24
months of age.15 The AAP also
MIODOVNIK et al
TABLE 1 Demographic and Clinical Characteristics of Children Stratified by Study Group (n = 1451)
ADHD Before ASD, n = 313 ADHD Same/After ASD, n = 392 ASD Only, n = 746 P
a a a
n (%) n (%) n (%)
Gender
Boys 260 (87.6) 333 (88.8) 591 (81.0) .08
Girls 53 (12.4) 59 (11.2) 154 (19)
Co-occurring conditions
Developmental delay 201 (58.6) 262 (75.1) 540 (75.9) .05
Intellectual disability 57 (19.3) 89 (20.9) 176 (26.7) .45
Speech problems 154 (53.4) 244 (70.8) 523 (74.8) .01
Race
White 265 (78.5) 306 (84.9) 552 (70.3) .12
Black 14 (15.6) 24 (7.2) 67 (11.4)
Other 31 (6.0) 57 (7.9) 113 (18.3)
Ethnicity
Hispanic 16 (17.8) 36 (14.3) 79 (24.1) .48
Non-Hispanic 293 (82.2) 351 (85.7) 654 (75.9)
Mother’s education
# High school diploma 68 (20.9) 87 (28.1) 162 (24.1) .62
. High school diploma 213 (79.1) 262 (71.9) 525 (75.9)
Household income
#200% FPL 111 (37.4) 146 (40.6) 241 (35.3) .03
.200% to #400% FPL 104 (45.7) 100 (22.1) 229 (38.8)
.400% FPL 79 (16.9) 119 (37.3) 214 (25.9)
Autism severity
Mild 182 (54.4) 199 (54.9) 423 (50.6) .29
Moderate 104 (36.8) 153 (38.4) 223 (33.2)
Severe 24 (8.8) 40 (6.6) 96 (16.3)
ASD diagnosed . 6 y old 258 (81.4) 100 (20.2) 165 (22.3) ,.001
Age at survey completion, y, mean 6 SE 11.8 6 0.4 10.8 6 0.4 10.0 6 0.3 .003
ASD age at diagnosis, y, mean 6 SE 8.6 6 0.4 4.7 6 0.3 4.6 6 0.2 ,.001
ADHD age at diagnosis, y, mean 6 SE 5.7 6 0.2 6.0 6 0.2 .32
Significant findings are bolded.
a All prevalence estimates were weighted using survey weights provided by NSCH data set to account for the complex survey design and better represent the noninstitutionalized

population of the United States and District of Columbia.

recommends careful developmental
surveillance at every well-child visit,
a process that emphasizes eliciting
parental concerns, considering family
history and observing the child
during visits.31 Despite the push for
routine screening and surveillance in
primary care, our study of children 2
to 17 years old found that, overall,
39.5% were not diagnosed until
6 years or older, similar to the
findings of other large surveillance
studies16 and population surveys.17
Barkley32 maintained that it was
common for children with pervasive
developmental disorder, not
otherwise specified, to initially
receive a diagnosis of ADHD. Jensen
et al33 reported that 74% of the
children diagnosed with pervasive
developmental disorder, not
otherwise specified, in their study
were originally diagnosed with
ADHD. Perry34 estimated that at
least half of the patients referred to
him for Asperger disorder had
previously been diagnosed with
ADHD. More recently, Mandell et al35
reported 21% of Medicaid-eligible
children with ASD seen in a mental
health clinic received a diagnosis of
ADHD before ASD. We found ∼20%
of children in our sample with ASD
had been diagnosed with ADHD
before ASD. Although an association
between milder cases and a later age
of ASD diagnosis was supported by
our findings, the delay in diagnosis
for the ADHD before ASD group
existed regardless of the age at
ADHD diagnosis or the severity of
the child’s ASD.
Most of the evidence for making an
accurate diagnosis of ASD in young
children is based on studies
conducted with experienced and
highly trained staff in research
settings. The NSCH reflects what
occurs in the population at large.
Community-based primary care
physicians are often the first to
encounter parental concerns about
their child’s development,36 yet the
variability in presenting symptoms
makes it challenging to diagnose ASD
in young children.37 Parents are less
likely to express specific concerns
about social development before
their child has been exposed to
a consistent peer group,38,39 and the
stereotypies and repetitive behaviors
that are required for the diagnosis of
ASD are often less pronounced at
younger ages.40 As a result, the
accuracy rate of ASD diagnosis
among general pediatricians has
remained relatively low.41–43
Conversely, .40% of clinically
evaluated children with ASD who are

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PEDIATRICS Volume 136, number 4, October 2015 e833
TABLE 2 Associations for Age at ASD Diagnosis and ASD Diagnosis . 6 y (n = 1212) reported using the Diagnostic and
b Coefficients for Age at ASD aOR for ASD Diagnosis .6 y Statistical Manual of Mental
Diagnosis, y (95% CI) (95% CI) Disorders, Fourth Edition criteria,
Gender and only 67% used standardized
Boys 0.07 (–0.78–0.91) 2.0 (0.83–4.71) rating scales in making the
Girls ref ref diagnosis.46 Because the
Co-occurring conditions prototypical behaviors and social
Developmental delay 20.62 (–1.25–0.02) 0.33 (0.18–0.62)**
Intellectual disability 20.55 (–1.05 to –0.05)* 0.51 (0.25–1.07)
deficits that characterize ASD may
Speech problems 21.20 (–1.86 to –0.54)*** 0.47 (0.25–0.86)* not manifest themselves in the
Race relatively short time frame allotted
White 0.08 (–0.47–0.63) 0.77 (0.32–1.85) for routine clinic visits,37 general
Black 20.04 (–0.74–0.66) 1.30 (0.39–4.32) practitioners may be inclined to
Other ref ref
Ethnicity
attribute maladaptive behaviors to
Hispanic 20.04 (–0.68–0.59) 1.16 (0.53–2.56) ADHD, the most common
Non-Hispanic ref ref neurobehavioral disorder of
Mother’s education childhood. This is especially true if
# High school diploma 0.37 (–0.20–0.93) 1.46 (0.65–3.30) they have more experience
. High school diploma ref ref
Household income
managing and treating ADHD, if they
#200% FPL 0.51 (–0.05–1.06) 1.82 (0.80–4.14) do not feel comfortable giving
.200% to #400% FPL 0.45 (–0.15–1.06) 1.27 (0.60–2.67) a diagnosis of ASD,47 or if they lack
.400% FPL ref ref access to specialists who can
Autism severity conduct comprehensive
Mild 1.69 (0.97–2.40)*** 7.53 (1.67–33.9)**
Moderate 1.33 (0.65–2.01)*** 6.47 (1.50–27.9)*
neurodevelopmental assessments.48
Severe ref ref However, ADHD is rarely an easy
Age at survey completion 0.33 (0.26–0.40)*** 1.41 (1.29–1.54)*** diagnosis to make in very young
ASD subgroups children.49,50 Although many of the
ADHD before ASD 2.87 (2.29–3.46)*** 16.7 (7.03–39.7)*** children in our study retained their
ADHD same/after ASD 20.31 (–0.86–0.24) 0.57 (0.28–1.15)
ASD only ref ref
ADHD diagnosis after their ASD
Adjusted for, gender, race, ethnicity, presence of developmental delay, speech problems, intellectual disability, maternal
diagnosis, 12.6% of those who were
education, household income, ASD severity, and age at survey completion. aOR, adjusted odds ratio. diagnosed at younger than 7 years of
*P , .05; **P , .01; ***P , .001. age reported having only ASD and
not ADHD at the time of survey
,6 years old have been found to adherence to the AAP guidelines for completion. Similarly, Law et al30
display symptoms of ADHD.26,44 ADHD diagnosis within primary care re-contacted children who had been
Published research suggests limited settings.45 Only 25% of pediatricians diagnosed with ADHD after
undergoing a multidisciplinary
consultation when they were
younger than 7 years; they found
that 7 years after the initial
evaluation, 11.4% of the children
reported having a current ASD
diagnosis but no longer carried the
original ADHD diagnosis.
Our findings are subject to several
limitations. First, the cross-sectional
design of the study precludes us
from making statements about the
causality of our associations.
Although the parent-reported
timing of ASD and ADHD diagnoses
allows us to examine the temporal
order of events, we cannot
FIGURE 1 prospectively control or account for
Predicted mean age at ASD diagnosis by age at ADHD diagnosis for ADHD before ASD (dark gray line) other intervening factors. Second,
and ADHD same/after ASD (light gray line). the indicators used here rely on

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e834 MIODOVNIK et al

FIGURE 2
Mean age at ASD diagnosis stratified by parent-reported ASD severity (mild, moderate, severe).
Adjusted for gender, race, ethnicity, maternal education, household income, and child’s age at survey
completion.
parent-reported diagnoses by
a health care provider, which is not
only subject to recall bias but lacks
the validity of clinical assessment
using standardized measures.
Without collateral information from
medical records or teacher reports,
what parents perceive as ADHD may
actually be within the normative
range of behavior for young
children. However, a recent analysis
indicated that parent-reported
survey data produced similar
estimates as those from insurance
claims data for ADHD51 and parent-
reported diagnosis of autism was
also consistent between 2 nationally
representative surveys,52 providing
evidence of convergent validity.
Although NSCH estimates are
potentially subject to survey
nonresponse bias, analyses of
nonresponse bias suggest that
differences between respondents
and nonrespondents should not
have a major impact on the
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PEDIATRICS Volume 136, number 4, October 2015
conclusions in this report.12 Finally,
information on the severity of ASD
at the time of diagnosis and the
diagnostic subtype of ASD were not
available. Therefore, we attempted
to control for this by using current
parent-reported ASD severity as
a proxy for baseline ASD severity in
our models.
CONCLUSIONS
We found a substantial number of
parents reporting an ADHD diagnosis
by a health care provider before an
ASD diagnosis. Moreover, these
children were significantly older
when they received their ASD
diagnosis compared with other
children diagnosed with ASD. Our
study supports the hypothesis that
receiving a diagnosis of ADHD before
ASD may delay the diagnosis of ASD,
and that this delay persists across age
and severity of the ASD. Furthermore,
if ADHD is diagnosed first, the ASD
diagnosis has a higher probability of
occurring late (ie, .6 years of age).
ASD that goes unrecognized and
untreated until the child is older may
negatively affect their long-term
prognosis.
Our findings have important
implications: (1) children with ADHD
before ASD may exhibit unique
dimensional traits that could bias
clinicians toward an ADHD diagnosis,
and (2) diagnostic criteria and
screening measures for ASD may
need to reflect the overlapping
symptomatology between ASD and
ADHD. However, prospective studies
are still needed to characterize the
overlapping and distinct phenotypic
presentations of individuals with
ADHD before ASD. For now, clinicians
should consider ASD when evaluating
young children presenting with ADHD
symptoms.
ABBREVIATIONS
AAP: American Academy of
Pediatrics
ADHD: attention-deficit/
hyperactivity disorder
ASD: autism spectrum disorder
CI: confidence interval
FPL: Federal Poverty Level
NSCH: National Survey of
Children’s Health
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Timing of the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Autism
Spectrum Disorder
Amir Miodovnik, Elizabeth Harstad, Georgios Sideridis and Noelle Huntington
Pediatrics; originally published online September 14, 2015;
DOI: 10.1542/peds.2015-1502
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
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Timing of the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Autism
Spectrum Disorder
Amir Miodovnik, Elizabeth Harstad, Georgios Sideridis and Noelle Huntington
Pediatrics; originally published online September 14, 2015;
DOI: 10.1542/peds.2015-1502

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2015/09/08/peds.2015-1502

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Univ of California San Diego on September 14, 2015