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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

February 2013: 

Combating Autism Act: 

HHS Agencies Responded with New and Continuing Activities, Including 
Oversight: 

GAO-13-232: 

GAO Highlights: 

Highlights of GAO-13-232, a report to congressional requesters. 

Why GAO Did This Study: 

CDC considers autism to be an important public health concern. In 
2012, CDC reported that an estimated 1 in 88 children in the United 
States has been identified as having autism—-a 23 percent increase 
from its estimate of 1 in 110 reported in 2009. Autism is a 
developmental disorder involving communication and social impairment. 
Symptoms usually become evident in early childhood. There are many 
suspected causes and no known cure. 

HHS agencies fund educational and support services for individuals 
diagnosed with autism and fund research in a variety of areas, such as 
identifying the causes of autism and intervention options. The CAA 
amended sections of the Children’s Health Act of 2000 related to 
autism and established new requirements. The CAA, enacted in December 
2006, authorized the expansion of HHS’s activities related to autism 
research, surveillance, prevention, intervention, and education 
through fiscal year 2011. The CAA authorized, but did not appropriate, 
federal funding to carry out these activities. 

In this report, GAO (1) describes the actions that HHS agencies have 
taken as a result of the CAA, and (2) examines the oversight of CAA 
grantees. To address these objectives, GAO reviewed CAA and HHS 
documents and interviewed agency officials to identify the autism 
activities resulting from the CAA. GAO also determined the amount 
certain HHS agencies spent on autism activities from fiscal year 2006—-
prior to the CAA—-through fiscal year 2011. In addition, GAO reviewed 
files for a random sample of CAA grantees to examine oversight from 
2008 to 2011. 

What GAO Found: 

Department of Health and Human Services (HHS) agencies responded to 
the Combating Autism Act of 2006 (CAA) by establishing some new autism 
activities and continuing others. The Health Resources and Services 
Administration (HRSA) created a new initiative to address specific 
directives in the CAA. Through this initiative, HRSA expanded its 
existing training programs by requiring grantees to include training 
specific to autism. It also established new autism research grants and 
funded new state grants to improve services for children with autism. 
HRSA awards its autism grants under the authority of the CAA. The 
National Institutes of Health (NIH) and Centers for Disease Control 
and Prevention (CDC) continued their autism activities—-some of which 
were undertaken in response to the Children’s Health Act of 2000-—but 
did not create new programs as a direct result of the CAA. NIH 
continued to fund, expand, and coordinate autism research through its 
Autism Centers of Excellence and autism-specific grants and contracts. 
CDC continued to fund its regional centers of excellence for autism 
epidemiology and other activities, such as an awareness campaign. 
HHS’s Interagency Autism Coordinating Committee (IACC)-—reauthorized 
by the CAA—-assumed additional responsibilities to coordinate autism 
efforts within HHS and restructured its membership to include more 
nonfederal members. NIH created the Office of Autism Research 
Coordination to coordinate and manage the IACC. The CAA did not 
appropriate funds to any HHS agency. Nevertheless, overall spending on 
HRSA, NIH, CDC, and IACC autism activities increased from 
approximately $143.6 million in fiscal year 2006 to approximately 
$240.4 million in fiscal year 2011. 

HRSA, the only HHS agency that has awarded grants specifically as a 
result of the CAA, regularly collects and reviews information from 
grantees to oversee individual CAA grantees and programs. HRSA awarded 
approximately $164 million in grants to 110 CAA grantees from fiscal 
years 2008 to 2011; though, some of these grantees were already 
receiving funds prior to the CAA. To oversee these grantees, HRSA 
requires they regularly submit progress reports and financial reports. 
The agency also requires grantees to obtain prior approval before 
making certain changes to their projects. GAO reviewed documentation 
for an unbiased random sample of 22 grantees, which were 
representative of the 110 CAA grantees. GAO found that CAA grantees 
submitted all required reports. Many grantees submitted prior-approval 
requests for changes to their projects. Most frequently, grantees 
requested to carry over unobligated funds from the current year to the 
next budget period. GAO found that HRSA staff routinely collected and 
reviewed information submitted by the grantees and appropriately 
documented their review and approval of these submissions. HRSA also 
conducted site visits and provided technical assistance as a means of 
overseeing grantees. HRSA conducted site visits with 9 of the grantees 
in our sample during the period of our review, while only 2 of these 
were required sites visits. Besides overseeing grantees, HRSA monitors 
its overall CAA programs by regularly collecting performance reports 
from grantees. In addition, in December 2012, HRSA released a grant-
management operations manual to outline its overall approach for 
monitoring its CAA programs. 

GAO provided a draft of this report to HHS for comment. In response, 
HHS provided technical comments that were incorporated, as appropriate. 

View [hyperlink, http://www.gao.gov/products/GAO-13-232]. For more 
information, contact Marcia Crosse at (202) 512-7114 or 
crossem@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

HHS Agencies Responded to the CAA by Establishing New Autism 
Activities and Continuing Others: 

HRSA Routinely Collects and Reviews Information to Oversee CAA 
Grantees: 

Agency Comments: 

Appendix I: National Institutes of Health's (NIH) and Centers for 
Disease Control and Prevention's (CDC) Autism Activities: 

Appendix II: List of Interagency Autism Coordinating Committee (IACC) 
Reports: 

Appendix III: Department of Health and Human Services (HHS) Funding 
for Autism Activities for Fiscal Years 2006 through 2011: 

Appendix IV: Combating Autism Act Grantees from Fiscal Years 2008 
through 2011 by Program: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Autism Programs and Funding Sponsored by the Health Resources 
and Services Administration (HRSA) as a Result of the Combating Autism 
Act, Fiscal Years 2008-2011: 

Table 2: NIH's and CDC's Autism Activities during Fiscal Years 2006 
through 2011: 

Table 3: Leadership Education in Neurodevelopmental and Other Related 
Disabilities Training Program Grantees from Fiscal Years 2008 through 
2011: 

Table 4: Developmental-Behavioral Pediatrics Training Program Grantees 
from Fiscal Years 2008 through 2011: 

Table 5: National Combating Autism Interdisciplinary Training Resource 
Center Grantees from Fiscal Years 2008 through 2011: 

Table 6: Autism Intervention Research Program and Autism Intervention 
Secondary Data Analysis Studies Program Grantees from Fiscal Years 
2008 through 2011: 

Table 7: Autism Intervention Research Network on Physical Health 
Grantees from Fiscal Years 2008 through 2011: 

Table 8: Autism Intervention Research Network on Behavioral Health 
Grantees from Fiscal Years 2008 through 2011: 

Table 9: Developmental-Behavioral Pediatrics Research Network Grantees 
from Fiscal Years 2008 through 2011: 

Table 10: State Implementation and Planning Grants Grantees from 
Fiscal Years 2008 through 2011: 

Table 11: State Public Health Coordinating Center Grantees from Fiscal 
Years 2008 through 2011: 

Abbreviations: 

CAA: Combating Autism Act of 2006: 

CDC: Centers for Disease Control and Prevention: 

DBP: Developmental-Behavioral Pediatrics: 

EHB: Electronic Handbook: 

HHS: Department of Health and Human Services: 

HRSA: Health Resources and Services Administration: 

IACC: Interagency Autism Coordinating Committee: 

LEND: Leadership Education in Neurodevelopmental and Other Related 
Disabilities: 

NIH: National Institutes of Health: 

NIMH: National Institute of Mental Health: 

OARC: Office of Autism Research Coordination: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

February 27, 2013: 

Congressional Requesters: 

The Centers for Disease Control and Prevention (CDC) considers autism 
to be an important public health concern. In March 2012, CDC--an 
agency within the Department of Health and Human Services (HHS)--
reported that an estimated 1 in 88 children in the United States had 
been identified as having autism--a 23 percent increase from its 
estimate of 1 in 110 children in 2009.[Footnote 1] Autism is 
characterized by impaired social interactions, problems with verbal 
and nonverbal communication, and repetitive behaviors, or by severely 
limited activities and interests. What is commonly known as "autism" 
is a group of disorders known as autism spectrum disorders.[Footnote 
2] Diagnoses include autistic disorder, a more severe form of autism, 
and Asperger syndrome, a milder form of autism. 

HHS agencies fund educational and support services for individuals 
diagnosed with autism and fund research, such as studies to identify 
the causes of autism and intervention options. Some of HHS's autism-
related activities are performed internally by its agencies, while 
others are conducted by external organizations. For example, HHS 
agencies award grants to institutions to conduct autism-related 
research and surveillance activities. Each HHS agency is responsible 
for overseeing the funds that it awards to external organizations to 
ensure that they are properly and effectively used. 

To address growing concern about the increasing prevalence of autism 
and to stimulate research into possible autism causes and 
interventions, the Combating Autism Act of 2006 (CAA) was enacted in 
December 2006.[Footnote 3] The CAA authorizes the expansion of HHS's 
activities related to autism research, surveillance, prevention, 
intervention, and education and authorizes funding for such activities 
through fiscal year 2011.[Footnote 4] You asked us to provide 
information on agencies' responses to the CAA and oversight of CAA 
activities. In this report, we (1) describe the actions that HHS 
agencies have taken as a result of the CAA, and (2) examine the 
oversight of CAA grantees.[Footnote 5] 

To describe the actions HHS agencies have taken as a result of the 
CAA, we reviewed CAA and agency documents and interviewed HHS 
officials. We focused our work on those HHS agencies directed to 
conduct autism activities included in the CAA--the Health Resources 
and Services Administration (HRSA), the National Institutes of Health 
(NIH), and CDC.[Footnote 6] We reviewed documents and interviewed 
agency officials to identify the autism activities each agency funded, 
whether those activities resulted from the CAA, and the amount spent 
on those activities. We included activities in our review that the 
agencies funded from fiscal years 2006 through 2011. Although the CAA 
was enacted during fiscal year 2007, we included fiscal year 2006 in 
our analysis to help determine the extent to which these agencies' 
activities and funding for autism activities changed following the 
enactment of the CAA. 

To examine the oversight of CAA grantees, we interviewed HHS officials 
at HRSA, NIH, and CDC to determine whether they had awarded CAA 
grants; reviewed agencies' grants oversight policies and procedures; 
and conducted a review of selected grantees' files. Specifically, we 
reviewed agency guidance documents that outline protocols and 
procedures for overseeing grantees.[Footnote 7] We also reviewed 
documents--such as funding opportunity announcements for CAA grants--
that outline CAA grantees' specific reporting requirements and other 
responsibilities. In addition, we interviewed agency officials about 
(1) policies and procedures for overseeing grantees and required 
oversight documentation, (2) the roles and responsibilities of various 
agency staff in the oversight process, and (3) grantee requirements. 
Lastly, we compared the grantee monitoring processes described by 
agency officials and documents to actual oversight activities. To do 
this, we selected an unbiased random sample of 20 percent of the CAA 
grantees--22 of the 110--funded between 2008 and 2011 and examined 
grant files and related documents.[Footnote 8] Our file review of the 
selected grantees included a review of required reports and requests 
grantees submitted; oversight of such reports and requests; and other 
documentation, such as site visit summaries, for the grants awarded in 
fiscal years 2008 through 2011. We reviewed documentation located in 
two data systems--the Electronic Handbook (EHB) and the Discretionary 
Grant Information System--that, according to agency officials, contain 
all significant documentation related to monitoring CAA grantees. 
[Footnote 9] To conduct this file review, we developed and used a data-
collection instrument to assess whether the files included evidence of 
required monitoring and key monitoring documents. For example, we 
reviewed whether grantees submitted required reports on time, and if 
agency officials appropriately documented their review and approval of 
these reports. While we identified key monitoring actions and 
documents, we did not assess the quality of these actions or 
documents. To assess the reliability of the data collected, we 
compared the information contained in the oversight documents we 
reviewed, information provided to us by agency officials, and 
information contained in the two data systems. If there were 
discrepancies between these sources of information, we asked HRSA to 
resolve the discrepancies and provide associated documentation. We 
found the data reliable for our purposes. 

We conducted this performance audit from March 2012 to February 2013 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings based on our audit objectives. We believe that the evidence 
obtained provides a reasonable basis for our findings and conclusions 
based on our audit objectives. 

Background: 

Autism--a complex and pervasive developmental disability--usually 
becomes evident in early childhood, although signs and symptoms vary. 
[Footnote 10] According to CDC, autism begins before age 3 and lasts 
throughout a person's life. Some children show signs of autism within 
the first few months of life. In others, symptoms might not appear 
until 24 months or later. Still other children with autism seem to 
develop typically until 18 to 24 months of age and then stop gaining 
new skills or lose the skills they once had. Signs and symptoms of 
autism include a child not responding to his or her name by 12 months; 
not pointing at objects to show interest by 14 months; avoiding eye 
contact and wanting to be alone; repeating words or phrases over and 
over; and flapping hands, rocking, or spinning in circles. Individuals 
with autism might have challenges with showing or talking about their 
feelings and might also have trouble understanding the feelings of 
others. 

Diagnosing autism can be difficult; however, early intervention 
services can greatly improve a child's development. There is no 
medical diagnostic test available for autism. As a result, doctors 
consider a child's behavior and development to make a clinical 
diagnosis. By age 2, a diagnosis by an experienced professional can be 
considered very reliable. However, according to CDC most children do 
not receive a diagnosis until after age 4. There is no single cause of 
autism, but a variety of factors are suspected of causing or 
contributing to autism, including environmental, biological, and 
genetic sources. While there is no known cure, research shows that 
early intervention services can greatly improve a child's development. 
Because of the complexity of this disorder, individuals with autism 
have diverse needs for medical and mental health care as well as an 
array of educational and social services. 

The CAA authorizes and directs HHS to conduct specific autism-related 
activities, which may include funding external organizations to 
conduct these activities through grants, contracts, and cooperative 
agreements.[Footnote 11] The CAA amended sections of the Children's 
Health Act of 2000--which required HHS to conduct activities related 
to autism research, surveillance, and coordination--by revising some 
sections and repealing other sections of that law as well as 
establishing new requirements.[Footnote 12] The CAA authorized, but 
did not appropriate, federal funding to carry out these activities in 
fiscal year 2007 through fiscal year 2011. 

HHS Agencies Responded to the CAA by Establishing New Autism 
Activities and Continuing Others: 

HHS agencies responded to the CAA with new or continuing autism 
activities. In fiscal year 2008, HRSA created the Combating Autism Act 
Initiative in response to specific directives included in the CAA. 
[Footnote 13] Through this initiative, HRSA expanded its existing 
training programs to include an autism-specific component and 
established new autism research and state grants. HRSA conducts all of 
its Combating Autism Act Initiative programs under the authority of 
the CAA. HRSA staff told us that they have not analyzed whether the 
agency's new programs could be conducted under other HRSA authority. 

HRSA expanded two of its preexisting training programs--the Leadership 
Education in Neurodevelopmental and Other Related Disabilities (LEND) 
and the Developmental-Behavioral Pediatrics (DBP) training programs--
through supplemental funding to existing grantees and awards to new 
grantees. These two training programs account for the majority of HRSA 
spending under its Combating Autism Act Initiative; however, HRSA was 
funding these programs prior to enactment of the CAA.[Footnote 14] 
Under the Combating Autism Act Initiative, LEND and DBP grantees are 
required to include an autism component in their training. Among other 
things, the programs train health care professionals, such as 
pediatric practitioners, residents, and graduate students, to provide 
evidence-based services to children with autism and other 
developmental disabilities and their families; and train specialists 
to provide comprehensive diagnostic evaluations to address the 
shortage of professionals who can confirm or rule out an autism 
diagnosis. According to HRSA, as a result of these training programs, 
the number of health professionals enrolled in autism courses 
increased from 1,887 in academic year 2008-2009 to 4,256 in academic 
year 2010-2011 and the number of diagnostic evaluations increased from 
12,390 in academic year 2008-2009 to 44,102 in academic year 2010-2011. 

Additionally, HRSA created new autism research programs to fund 
studies that are intended to advance the current autism knowledge base 
and lead to improvements in interventions that address the health and 
well-being of children and adolescents with autism and other 
developmental disabilities. HRSA also provided grants to establish two 
research networks that focus on the physical and behavioral health 
needs of children and adolescents with autism. These networks conduct 
research on evidence-based practices for interventions, promote the 
development of evidence-based guidelines for intervention, validate 
tools for autism intervention, and disseminate information to health 
professionals and the public, especially families affected by autism. 

HRSA also funded new state implementation and planning grants to 
implement plans to improve access to comprehensive, coordinated health 
care and related services for children and youth with autism and other 
developmental disabilities. Twenty-two states received grants from 
fiscal years 2008 to 2011 to implement their autism plans.[Footnote 
15] These plans vary by state, but common elements include a focus on 
partnerships between professionals and families of children and youth 
with autism, access to a culturally competent family-centered medical 
home, access to adequate health insurance and financing of services, 
early and continuous screening for autism and other developmental 
disabilities, community services organized for easy use by families, 
and transition services for youth entering adult health care. Table 1 
provides information on the specific autism-related programs HRSA 
initiated or expanded--by increasing funding and the number of 
grantees--as a result of the CAA. 

Table 1: Autism Programs and Funding Sponsored by the Health Resources 
and Services Administration (HRSA) as a Result of the Combating Autism 
Act, Fiscal Years 2008-2011: 

Programs: Leadership Education in Neurodevelopmental and Other Related 
Disabilities (LEND) Training Program; 
Type of program: Training; 
Purpose of program: Improve the health of children who have, or are at 
risk for developing, neurodevelopmental and other related disabilities 
by training professionals to assume leadership roles, and to ensure 
high levels of interdisciplinary clinical competence in an effort to 
increase diagnosis of or rule out individuals with developmental 
disabilities, including autism; 
Number of grantees, fiscal years 2008-2011: 47[A]; 
Total funding, fiscal years 2008-2011: $107.2 million[A]. 

Programs: Developmental-Behavioral Pediatrics (DBP) Training Program; 
Type of program: Training; 
Purpose of program: Train the next generation of leaders in 
developmental-behavioral pediatrics; and provide pediatric 
practitioners, residents, and medical students with essential 
biopsychosocial knowledge and clinical expertise. This program is 
focused on developmental disabilities, including autism; 
Number of grantees, fiscal years 2008-2011: 10; 
Total funding, fiscal years 2008-2011: $7.3 million. 

Programs: National Combating Autism Interdisciplinary Training 
Resource Center; 
Type of program: Training; 
Purpose of program: Improve the health of children who have, or are at 
risk for developing, autism and other developmental disabilities by 
providing technical assistance to LEND and DBP programs to better 
train professionals to utilize valid and reliable screening tools for 
diagnosing or ruling out autism, and provide evidence-based 
interventions for children; 
Number of grantees, fiscal years 2008-2011: 1; 
Total funding, fiscal years 2008-2011: $2.5 million. 

Programs: Autism Intervention Research Program and Autism Intervention 
Secondary Data Analysis Studies Program; 
Type of program: Research; 
Purpose of program: Support research on evidence-based practices for 
interventions to improve the health and well-being of children and 
adolescents with autism and other developmental disabilities. The 
Autism Intervention Secondary Data Analysis Studies Program utilizes 
the analysis of existing secondary data; 
Number of grantees, fiscal years 2008-2011: 26[B]; 
Total funding, fiscal years 2008-2011: $10.0 million[B]. 

Programs: Autism Intervention Research Network on Physical Health; 
Type of program: Research; 
Purpose of program: Establish and maintain a network infrastructure 
designed to be the platform from which to conduct research on evidence-
based practices for interventions to improve the physical health and 
well-being of individuals with autism and other developmental 
disabilities; develop evidence-based guidelines and validate tools for 
interventions; and disseminate critical information on its research 
findings, guidelines, and tools; 
Number of grantees, fiscal years 2008-2011: 1; 
Total funding, fiscal years 2008-2011: $15.6 million. 

Programs: Autism Intervention Research Network on Behavioral Health; 
Type of program: Research; 
Purpose of program: Establish and maintain a network infrastructure 
designed to be the platform from which to conduct research on evidence-
based interventions to improve the behavioral, mental, social, or 
cognitive health, or a mix of those, and well-being of children and 
adolescents with autism and other developmental disabilities; develop 
evidence-based guidelines and validate tools for interventions; and 
disseminate critical information on its research findings, guidelines, 
and tools; 
Number of grantees, fiscal years 2008-2011: 1; 
Total funding, fiscal years 2008-2011: $7.9 million. 

Programs: Developmental-Behavioral Pediatric Research Network; Type of 
program: Research; 
Purpose of program: Establish a multicenter scientific and clinical 
research network that will promote coordinated research activities and 
address health issues. Build a developmental behavioral pediatric 
research infrastructure that supports multidisciplinary research, 
focuses on the translation of research to practice, and provides the 
environment in which to train a new generation of developmental 
behavioral pediatric researchers; 
Number of grantees, fiscal years 2008-2011: 1; 
Total funding, fiscal years 2008-2011: $0.4 million. 

Programs: State Implementation and Planning Grants[C]; Type of 
program: Other; 
Purpose of program: Improve access to comprehensive, coordinated 
health care and related services by implementing state plans to 
improve the system of services; 
Number of grantees, fiscal years 2008-2011: 22; 
Total funding, fiscal years 2008-2011: $11.8 million[D]. 

Programs: State Public Health Coordinating Center; Type of program: 
Other; 
Purpose of program: Improve the health of children who have, or are at 
risk for developing, autism and other developmental disabilities by 
coordinating with the state implementation and planning grantees; and 
by developing a strategy for defining, supporting, and monitoring the 
role of state public health agencies in assuring early and timely 
identification, diagnosis, and intervention; 
Number of grantees, fiscal years 2008-2011: 1; 
Total funding, fiscal years 2008-2011: $1.1 million. 

Total: 
Number of grantees, fiscal years 2008-2011: 110; 
Total funding, fiscal years 2008-2011: $163.8 million[E]. 

Source: GAO analysis of HRSA documents and interviews with HRSA 
officials. 

Notes: HRSA's funds shown in this table were not appropriated by the 
Combating Autism Act (CAA). To fund these programs, HRSA used funds 
appropriated to the agency annually through the budget and 
appropriations process for the purpose of carrying out a variety of 
programs. Although the LEND and DBP training programs were established 
prior to the act, HRSA expanded these programs as a result of the act. 

[A] These totals include one funding supplement to an existing 
cooperative agreement to provide technical assistance to LEND 
grantees. A cooperative agreement is an alternative assistance 
instrument used instead of a grant whenever substantial federal 
involvement with the recipient during performance is anticipated. 

[B] These totals include one funding supplement to an existing 
cooperative agreement to examine current knowledge, research gaps, and 
methodological challenges about the life-course trajectory of 
individuals with autism, and develop a life-course-focused autism 
research agenda. 

[C] This program comprises: State Implementation Grants for Improving 
Services for Children and Youth with Autism Spectrum Disorder and 
other Developmental Disabilities, and State Planning Grants for 
Improving Services for Children and Youth with Autism Spectrum 
Disorder and other Developmental Disabilities. 

[D] This total includes supplemental funding provided to four state 
implementation and planning grantees to expand implementation of the 
Centers for Disease Control and Prevention's (CDC) Learn the Signs. 
Act Early. campaign, through an interagency agreement between HRSA and 
CDC. 

[E] Individual funding entries do not sum to total due to rounding. 

[End of table] 

NIH and CDC continued the autism activities each implemented prior to 
the enactment of the CAA, but did not create new programs as a direct 
result of the CAA. Some of these activities had been undertaken in 
response to the Children's Health Act of 2000, which, like the CAA, 
charges NIH with expanding, intensifying, and coordinating research on 
autism. In addition, under both laws, CDC is required to conduct 
activities related to establishing regional centers of excellence to 
collect and analyze certain information on autism.[Footnote 16] Since 
the enactment of the CAA, NIH continued to fund, expand, and 
coordinate autism research through its Autism Centers of Excellence 
and autism-specific grants and contracts. According to agency 
officials, NIH awards these grants and contracts under its general 
Public Health Service Act authorities and not under the specific 
authorities provided in the CAA.[Footnote 17] CDC continued to fund 
its regional centers of excellence for autism epidemiology and other 
activities, such as an awareness campaign on autism and other 
developmental disabilities. While enactment of the CAA did not result 
in any change to CDC's autism activities, CDC officials stated that 
the CAA provided additional focus on these efforts. According to CDC 
officials, the CAA's enactment also strengthened the agency's Learn 
the Signs. Act Early. awareness campaign by elevating the importance 
of increasing awareness of developmental milestones to national 
visibility. See appendix I for a list of NIH's and CDC's autism 
efforts. 

As required by the CAA, the Interagency Autism Coordinating Committee 
(IACC)--initially established under the Children's Health Act--
restructured its membership and assumed additional responsibilities to 
coordinate autism efforts within HHS. The CAA reauthorized the IACC 
and specified that the IACC include both federal and nonfederal 
members.[Footnote 18] IACC membership expanded to include 11 
nonfederal members that represented individuals with autism and 
parents of children with autism. In addition, it included members of 
the autism advocacy, research, and service-provider communities in 
accordance with the CAA's membership requirements. The CAA also 
directed the IACC to develop and annually update a strategic plan and 
summary of advances in autism research, and monitor federal autism 
activities.[Footnote 19] Since fiscal year 2007, the IACC issued 
several reports as a means to coordinate HHS autism efforts and 
monitor federal autism activities, some of which were specifically 
required by the CAA, such as the development of an autism strategic 
plan and a summary of advances in autism research.[Footnote 20] See 
appendix II for a description of the documents produced by the IACC. 

In addition to the changes to the IACC, in 2008, NIH created the 
Office of Autism Research Coordination (OARC) within the National 
Institute of Mental Health (NIMH) to coordinate and manage the IACC 
and related cross-agency activities, programs, and policies. OARC 
assists the IACC by conducting analyses and preparing reports for the 
IACC, assisting with the IACC's strategic planning and autism research 
monitoring, and providing logistical support for IACC meetings. It 
also supports communications through the IACC website and press 
releases, and responds to inquiries from the public and other 
government agencies.[Footnote 21] OARC officials told us that although 
HHS could establish an advisory committee similar to the IACC under 
other authority, the CAA has provided the IACC with greater visibility 
and increased involvement of the public and federal agencies, through, 
for example, the annual update of the IACC's autism strategic plan. 

Following the enactment of the CAA, HHS agencies continued to fund 
existing activities and funded new activities.[Footnote 22] Overall, 
spending on HRSA, NIH, CDC, and IACC autism activities increased from 
approximately $143.6 million in fiscal year 2006 to approximately 
$240.4 million in fiscal year 2011. HRSA spent more money on its 
autism programs beginning in fiscal year 2008 as a result of 
implementing its Combating Autism Act Initiative. From fiscal year 
2008 through fiscal year 2010 HRSA increased this spending by an 
average of $5.75 million annually. HRSA's spending on autism programs 
totaled approximately $47.9 million in fiscal year 2010. In fiscal 
year 2011, HRSA spent slightly less on these programs.[Footnote 23] 
Although the CAA did not provide appropriations for NIH's and CDC's 
autism activities, nor did Congress provide the agencies a specific 
autism appropriation after the CAA's enactment, NIH and CDC increased 
their overall spending on autism from fiscal year 2006 to fiscal year 
2011. NIH spent more money on its autism activities in fiscal years 
2009 and 2010 as a result of an appropriation for scientific research 
that it received under the American Recovery and Reinvestment Act of 
2009. And, according to CDC officials, the agency redirected a portion 
of its funding for infant health activities to support pilot projects 
implementing the agency's awareness campaign on autism and other 
developmental disabilities. The IACC's funding increased significantly 
from fiscal year 2006 to 2011. From fiscal year 2008 through fiscal 
year 2011, as directed by Congress in the annual HHS appropriations 
act, the Secretary of Health and Human Services transferred funds to 
NIMH for the IACC. From fiscal year 2006 through fiscal year 2011, the 
IACC also received funds from the annual NIH appropriation. See 
appendix III for information on the funding for these agencies' and 
the IACC's autism-related activities. 

HRSA Routinely Collects and Reviews Information to Oversee CAA 
Grantees: 

HRSA, the only HHS agency that awarded grants specifically as a result 
of the CAA, regularly collects and reviews information from grantees 
to oversee individual CAA grantees as well as to provide oversight to 
its CAA programs.[Footnote 24] HRSA awarded approximately $164 million 
in grants to 110 CAA grantees from fiscal years 2008 to 2011. The 
majority of funding--about $107 million--was awarded to 47 grantees 
within HRSA's LEND training program, some of which were already 
receiving funds prior to the CAA. In addition, nearly $24 million was 
awarded to two grantees to support HRSA's two autism intervention 
research networks. For all grantees, the amount of the grant award per 
year ranged widely from about $36,000 to $4 million depending on the 
CAA program, as shown in appendix IV. 

As part of the agency's oversight of its CAA grantees, HRSA requires 
periodic reports from these grantees, which are reviewed by HRSA 
staff. HRSA project officers within the Maternal and Child Health 
Bureau--the bureau that administers the CAA programs--are responsible 
for working with CAA grantees in overseeing the programmatic and 
technical aspects of the grant. HRSA grants management specialists and 
their supervisors--grants management officers--oversee compliance with 
financial reporting requirements and agency grant policies and 
regulations. The required reports that are reviewed by HRSA staff 
include the following: 

* Annual federal financial report. The annual federal financial report 
is an accounting of expenditures under the project in the budget 
period--the period for which HRSA has awarded funds to the grantee--
and cumulatively for the project period.[Footnote 25] The report is 
due after the end of the budget year. 

* Annual progress reports. The annual progress report is part of a 
grantee's noncompeting continuing application and describes grantees' 
progress on their grant objectives. Progress reports are due before 
the end of the budget period because HRSA staff use these reports to 
assess progress and, except for final progress reports, to determine 
whether to provide funding for the budget period subsequent to that 
covered by the report.[Footnote 26] 

* Mid-project progress reports. Mid-project progress reports provide 
information on grantees' progress on research objectives. These 
reports are required of certain research grantees and are due midway 
through the project period.[Footnote 27] 

* Semiannual progress reports. Semiannual progress reports include 
information on the grantees' most significant achievements and 
problems encountered during the reporting period as well as the 
grantees' progress on established objectives. These reports are 
required of research network grantees and are due midway through each 
budget period.[Footnote 28] 

In addition to reports, HRSA also requires grantees to submit written 
requests before making certain changes to the grant project, known as 
prior-approval requests. For example, a change in the director of the 
grant project requires prior approval, as does a request to carry over 
unobligated funds to the next budget period or a request for a no-cost 
extension--an extension for a limited period beyond the end of the 
project period so that the grantee can complete project activities. 

When reviewing these reports and grantee prior-approval requests, HRSA 
staff are required to fill out checklists in the EHB in which they 
indicate their review and approval of the report or request.[Footnote 
29] The content of the review checklists varies by the type of report 
or request being reviewed. For example, among other questions, a 
progress report checklist asks if the report reflects the program's 
goals. The federal financial report checklist asks HRSA staff to 
compare the report with data in HRSA's payment management 
system.[Footnote 30] All review checklists include a question where 
HRSA staff can indicate if they have identified any issues or concerns 
with the report or request. In addition, when reviewing grantee 
information, HRSA staff may request that a report be revised with 
additional or corrected information. 

Our review found that HRSA routinely collects and reviews information 
submitted by CAA grantees. Generally, grantees submitted required 
reports and HRSA staff documented their review of these reports. 
Specifically, the 22 grantees in our unbiased random sample[Footnote 
31] submitted all of the 106 reports they were required to submit and 
most of these reports were submitted on time.[Footnote 32] We found 
that HRSA staff filled out checklists approving all of the reports 
submitted or required report revisions. In many cases, HRSA staff 
filled out a checkbox indicating a "yes," "no," or "n/a" response to 
the questions. However, we noted that there were some cases where 
staff provided a narrative description to support their response to 
the question, such as a description of how the grantee is meeting the 
program's goals--a question in the progress report checklist. HRSA 
officials stated that staff are required to answer the questions in 
the checklist, but they are not required to provide a narrative 
supporting their answers. 

We observed that there were few instances of HRSA staff either 
documenting a concern or asking for a report revision before approving 
the report. We encountered seven instances where a project officer 
approved a report, but documented a concern in a checklist. In all 
these instances, the project officer provided narrative describing the 
concern.[Footnote 33] For example, in one instance, the project 
officer wrote that the grantee's recruitment of study subjects--
parents of children with autism or other developmental disabilities--
was slow. However, the project officer also stated that the grantee 
modified its enrollment process, which seemed to be having some 
positive effect and that the project officer and grantee were working 
together to monitor enrollment. We also identified another seven 
instances where HRSA staff asked for a report to be revised either 
with additional or corrected information. In almost all instances, the 
grantees submitted a revised report and HRSA staff completed a 
checklist indicating approval of the revised report.[Footnote 34] 

We also found that grantees submit a number of prior-approval 
requests, which HRSA staff review and generally approve. Most 
frequently, grantees request to carry over unobligated funds from the 
current year to the next budget period. For example, 13 of the 22 
grantees in our review requested to carry over unobligated balances at 
least once during the period of our review, and many of them requested 
it for multiple years--equaling 32 separate requests. The amount of 
unobligated balances that grantees requested to carry over in a given 
year ranged from $1,518 to $172,514. In all instances, HRSA approved 
these requests as indicated by the issuance of a revised notice of 
award.[Footnote 35] Almost all requests related to awards in fiscal 
year 2010 and later contained an associated checklist in the EHB 
filled out by HRSA staff approving the request to carry over 
unobligated balances.[Footnote 36] 

In addition to reviewing information submitted by grantees, HRSA 
provides additional oversight to grantees. First, it conducts site 
visits in person or by means of the web. During a site visit, HRSA 
staff may collect information on preliminary research findings, data 
and analysis, and any challenges the grantee is facing. Site visits 
are only required of certain research grantees, although HRSA may 
conduct site visits with other grantees, depending on available 
resources.[Footnote 37] HRSA officials target site visits for CAA 
grantees on the basis of six criteria: (1) the grantee is new, (2) 
there has been a change in the grantee's project director, (3) there 
has been a change in the grantee's scope of work, (4) there are 
budgetary issues or the grantee has not made adequate progress on the 
project goals, (5) the grantee has requested technical assistance, or 
(6) there has been a change in the project officer overseeing the 
grantee. HRSA uses a site-visit report to document the visit and has 
guidance on what should be included in the report. For example, for 
training grants, the report should include a narrative summary of the 
visit including highlights, performance measure progress, strengths 
and challenges, and any technical assistance needed by the grantee. 
Second, HRSA officials stated that HRSA project officers provide 
routine technical assistance to certain grantees and others on an as-
needed basis. For example, all research grantees have either a 
monthly, biweekly, or mid-project telephone call with HRSA project 
officers. 

Our review confirmed that HRSA has conducted a number of site visits 
to monitor CAA grantees. For example, nine of the grantees in our 
review had documentation indicating that a site visit had been 
conducted, with only two of these being required site visits. While 
none of the site-visit reports identified major issues that required 
corrective action, some did record challenges the grantees were facing 
or made suggestions. For example, one report stated that the grantee 
may encounter challenges in the recruitment of trainees. We identified 
documentation related to technical assistance that HRSA staff provided 
to some grantees but not all. For example, we did not always see 
documentation of routine telephone calls with research grantees that 
HRSA officials say occur on a regular basis. In response, HRSA 
officials stated that not all technical assistance is recorded in the 
EHB; only when a significant issue arises is the telephone call, e-
mail, or other assistance recorded. 

Besides overseeing specific grantees, HRSA monitors its CAA activities 
at the program level by regularly collecting performance reports from 
grantees.[Footnote 38] The 22 CAA grantees in our sample submitted all 
the required performance reports. According to HRSA officials, the 
primary purpose of performance reports is to gauge program 
performance. For example, data in performance reports is currently 
being used by a HRSA contractor to prepare a report on the progress of 
the CAA programs for Congress.[Footnote 39] In addition, according to 
HRSA officials, performance data can be used to modify program 
performance measures over time. While performance reports are used to 
monitor CAA programs--as opposed to grantees--HRSA officials stated 
that some performance information is also included in annual progress 
reports, which are used to oversee specific grantees. For example, 
progress reports require grantees to include information on whether 
they are having problems meeting their performance measures. Finally, 
to further help oversee CAA programs and consolidate information on 
its monitoring approach for these programs, in December 2012 HRSA 
released a grant-management operations manual to outline its overall 
approach for monitoring these programs.[Footnote 40] According to HRSA 
officials, this manual will be included in the program folder of the 
EHB for each of its CAA programs and will be reviewed annually, 
consistent with HHS guidance.[Footnote 41] 

Agency Comments: 

We provided a draft of this report to HHS for comment. HHS provided 
technical comments that we incorporated, as appropriate. 

We are sending a copy of this report to the Secretary of Health and 
Human Services. In addition, the report is available at no charge on 
the GAO website at [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or crossem@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix V. 

Signed by: 

Marcia Crosse: 
Director, Health Care: 

List of Requesters: 

The Honorable Tom Coburn, M.D. 
Ranking Member: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable Ron Johnson: 
United States Senate: 

The Honorable Mike Lee: 
United States Senate: 

The Honorable Robert Menendez: 
United States Senate: 

[End of section] 

Appendix I: National Institutes of Health's (NIH) and Centers for 
Disease Control and Prevention's (CDC) Autism Activities: 

During fiscal year 2006 through fiscal year 2011, NIH and CDC funded a 
number of autism activities. Table 2 lists the activities these 
agencies funded, including the type and purpose of each activity. 

Table 2: NIH's and CDC's Autism Activities during Fiscal Years 2006 
through 2011: 

Agency: NIH; 

Activity: Autism Centers of Excellence Program[A]; 
Type of activity: Research; 
Purpose of activity: NIH initiative that supports large-scale 
multidisciplinary studies on autism, with the goal of determining the 
disorders' causes and the best treatments for them. 

Activity: Collaborative Programs of Excellence in Autism[A]; 
Type of activity: Research; 
Purpose of activity: Conduct research to learn about the possible 
causes of autism, including genetic, immunological, and environmental 
factors; as well as diagnosis, early detection, behavioral and 
communications characteristics, and treatment of autism. 

Activity: Studies to Advance Autism Research and Treatment Network[A]; 
Type of activity: Research; 
Purpose of activity: Support and conduct both individual and 
collaborative projects to learn more about the causes, diagnosis, 
early detection, prevention, and treatments of autism. 

Activity: Children's Environmental Health and Disease Prevention 
Research Centers (with Environmental Protection Agency)[B]; 
Type of activity: Research; 
Purpose of activity: Examine the effect of environmental exposures on 
children's health. 

Activity: Research Units on Pediatric Psychopharmacology Autism 
Network; 
Type of activity: Research; 
Purpose of activity: Agency: Clinical trials evaluating 
psychopharmacological treatments for co-occurring behavior disorders 
in autism. 

Activity: Research to Address the Heterogeneity in Autism Spectrum 
Disorders; 
Type of activity: Research; 
Purpose of activity: Address gaps identified in the Interagency Autism 
Coordinating Committee's Strategic Plan and other knowledge gap areas 
related to autism, and to ensure appropriate attention is given to the 
most critical short-term objectives within the Strategic Plan. 
Applications for research projects were solicited within the following 
topic areas [relevant to research on the heterogeneity of autism]: 
measurement development, biomarkers/biological signatures, immune and 
central nervous systems interactions, genetics/genomics, environmental 
risk factors, model development, treatment and intervention, and 
services research. 

Activity: Challenge Grants in Health and Science Research[B]; 
Type of activity: Research; 
Purpose of activity: Support research on topic areas that address 
specific scientific and health research challenges in biomedical and 
behavioral research that would benefit from significant 2-year startup 
funds. 

Activity: Grand Opportunities grants[B]; 
Type of activity: Research; 
Purpose of activity: Support high-impact ideas that lend themselves to 
short-term funding, and may lay the foundation for new fields of 
investigation. The grants program will support large-scale research 
projects that accelerate critical breakthroughs, early and applied 
research on cutting-edge technologies, and new approaches to improve 
the synergy and interactions among multi-and interdisciplinary 
research teams. The initiative seeks novel approaches in areas that 
address specific knowledge gaps, scientific opportunities, new 
technologies, data generation, or research methods that would benefit 
from an influx of funds to quickly advance the area in significant 
ways. 

Activity: Initiative related to nonverbal school-age children; 
Type of activity: Research; 
Purpose of activity: Opportunity for investigators and U.S. 
institutions/organizations with certain active grants to submit 
revision applications to support an expansion of the scope or research 
protocol to develop preliminary investigations into the 
characterization and/or treatment of nonverbal school-aged children 
with autism. 

Activity: Contract related to Health Outcomes for Children with Autism 
and their Families; 
Type of activity: Research; 
Purpose of activity: Describe the health and health care trajectories 
of individuals with autism and their families, and evaluate the 
feasibility of using a large population-based database for research on 
risk factors for autism. 

Activity: National Institute of Mental Health Intramural Research 
Program, Autism Research; 
Type of activity: Research; 
Purpose of activity: Accelerate development and testing of innovative 
treatments. NIH has undertaken activities to address the effectiveness 
and outcomes of innovative and newly developed intervention strategies 
for individuals diagnosed with autism or other developmental 
disabilities. 

Activity: Eunice Kennedy Shriver National Institute of Child Health 
and Human Development Brain and Tissue Bank for Developmental 
Disorders[B]; 
Type of activity: Research; 
Purpose of activity: Advance the research of developmental disorders. 
The objective of this human-tissue repository is to systematically 
collect, store, and distribute brain and other tissues for research 
dedicated to the improved understanding, care, and treatment of 
individuals with developmental disorders. 

Activity: NIH National Database for Autism Research; 
Type of activity: Research; 
Purpose of activity: Accelerate autism research by creating an 
infrastructure that integrates heterogeneous datasets allowing access 
to much more quality research data than investigators would be able to 
collect on their own. 

Activity: National Institute of Mental Health Center for Collaborative 
Genetic Studies of Mental Disorders[B]; 
Type of activity: Research; 
Purpose of activity: Accelerate progress toward understanding genetic 
origins of mental disorders including autism, schizophrenia, bipolar 
disorder, and depression. Encourage the sharing of biological as well 
as clinical and genetic data from individuals or families with these 
disorders, and perform and disseminate analyses of these data. 

Activity: Psychosocial/Behavioral Interventions and Services Research 
in Autism Spectrum Disorders; 
Type of activity: Research; 
Purpose of activity: Facilitate exploratory research on 
psychosocial/behavioral treatments and innovative services research 
for autism, including the development of instruments to evaluate the 
impact of interventions on core features of autism, and comorbid 
symptomatology. 

Activity: Research on Autism and Autism Spectrum Disorders; 
Type of activity: Research; 
Purpose of activity: Supports research designed to elucidate the 
etiology, epidemiology, diagnosis, treatment, and optimal means of 
service delivery in relation to autism. 

Activity: Shared Neurobiology of Fragile X Syndrome and Autism; 
Type of activity: Research; 
Purpose of activity: Aimed at characterizing, understanding, and 
treating etiological and pathophysiological mechanisms common to both 
Fragile X syndrome and autism. 

Activity: Minnesota Somali Project (with CDC)[C]; 
Type of activity: Surveillance; 
Purpose of activity: Investigate reports of elevated prevalence of 
autism among children born to Somali immigrants living in Minneapolis, 
Minn. 

Agency: CDC; 

Activity: Metropolitan Atlanta Developmental Disabilities Surveillance 
Program; 
Type of activity: Surveillance; 
Purpose of activity: Provide regular and systematic monitoring of 
prevalence rates of selected developmental disabilities according to 
various demographic characteristics of children and their mothers and 
provide a framework for initiating special studies of children who 
have the selected developmental disabilities by establishing a 
population-based case series of such children. 

Activity: Autism and Developmental Disabilities Monitoring Network; 
Type of activity: Surveillance; 
Purpose of activity: Collaborative project to characterize the 
population prevalence and characteristics of children with autism and 
other developmental disabilities. Goals are to: provide data about how 
common autism is in a specific place and time period; describe the 
population of children with autism; compare how common autism is in 
different areas of the country; identify changes in autism occurrence 
over time; and understand the impact of autism and related conditions 
in U.S. communities. 

Activity: Autism Spectrum Disorder Surveillance of Younger Children 
(Pilot Alternative Surveillance); 
Type of activity: Surveillance; 
Purpose of activity: Investigate the feasibility of combining 
developmental screening and monitoring prevalence of autism for 
children under the age of 4. 

Activity: Centers for Autism and Developmental Disabilities Research 
and Epidemiology Network; 
Type of activity: Research; 
Purpose of activity: Regional centers of excellence for autism and 
other developmental disabilities. The primary activity of the network 
is to conduct the Study to Explore Early Development--a collaborative, 
multisite epidemiologic study of risk factors for autism. 

Activity: Centers for Autism and Developmental Disabilities Research 
and Epidemiology Data Coordinating Center; 
Type of activity: Research; 
Purpose of activity: Provide a centralized, web-based, automated-
workflow system that supports all of the study activities for the 
Study to Explore Early Development, cited above. 

Activity: Georgia Study to Explore Early Development; 
Type of activity: Research; 
Purpose of activity: The Study to Explore Early Development is a 
multiyear, multisite study in six diverse areas that looks at possible 
causes of and risks for autism and other developmental delays. 

Activity: CDC-Denmark Program; 
Type of activity: Research; 
Purpose of activity: Examine a variety of public health issues, 
including autism and other developmental disabilities. All studies in 
this program have a basic activity of either improving existing 
registries, conducting registry-based studies, or both. 

Activity: Minnesota Somali Project (with NIH)[C]; 
Type of activity: Surveillance; 
Purpose of activity: Investigate reports of elevated prevalence of 
autism among children born to Somali immigrants living in Minneapolis, 
Minn. 

Activity: Blood Spot Project (award managed by the Department of 
Defense); 
Type of activity: Research; 
Purpose of activity: Investigate the relationship between development 
of autism and cross-reactive antibodies that may cause alterations in 
fetal brain development. Archived dried blood spots from newborn 
children who later developed autism and from others who developed 
normally will be analyzed for specific antibodies. This project is 
funded by the Department of Defense. 

Activity: Learn the Signs. Act Early[B]; 
Type of activity: Awareness campaign/information dissemination; 
Purpose of activity: The program is made up of three components: (1) 
health education campaign promotes awareness of healthy developmental 
milestones in early childhood, the importance of tracking each child's 
development, and the importance of acting early if there are concerns; 
(2) Act Early Initiative works with state, territorial, and national 
partners to improve early childhood systems by enhancing collaborative 
efforts to improve screening and referral to early intervention 
services and supporting the work of Act Early Ambassadors to promote 
Learn the Signs. Act Early. messages and tools and improve early 
identification efforts in their state; and (3) research and evaluation 
improves campaign materials and implementation activities, and 
increases our understanding of the factors that influence early 
identification and referral. 

Source: GAO analysis of NIH and CDC documents and interviews. 

Notes: NIH and CDC funded these autism activities at some point 
between fiscal years 2006 through 2011, but did not necessarily fund 
each activity in every fiscal year. In addition to the autism research 
funded through these activities, NIH funded autism research through 
other mechanisms, such as through general grant announcements not 
specific to autism. 

[A] In fiscal year 2007 and 2008, respectively, the Collaborative 
Programs of Excellence in Autism and the Studies to Advance Autism 
Research and Treatment Network expired. NIH consolidated the funding 
and goals of these programs into the Autism Centers of Excellence 
Program. 

[B] While these activities are not autism-specific, they include an 
autism component, such as autism-specific research grants. 

[C] This activity was also partially funded by a private organization. 

[End of table] 

[End of section] 

Appendix II: List of Interagency Autism Coordinating Committee (IACC) 
Reports: 

Report: Strategic Plan for Autism Spectrum Disorder Research (2009, 
2010, 2011); 
Description: According to the IACC, the Strategic Plan provides a 
blueprint for autism research that is advisory to the Department of 
Health and Human Services and serves as a basis for partnerships with 
other agencies and private organizations involved in autism research 
and services. The 2011 Strategic Plan is organized around seven 
questions asked by individuals with autism and their families (such as 
"When should I be concerned?"). Each of the seven sections includes a 
description of what is generally known from autism research for that 
particular question and what gaps remain, followed by what was learned 
during the previous year. The report also sets up short-and long-term 
research objectives based on autism research opportunities. The 
Combating Autism Act of 2006 (CAA) requires that the Strategic Plan be 
updated on an annual basis. 

Report: Autism Spectrum Disorder Research Portfolio Analysis Report 
(2008, 2009, 2010)[A]; 
Description: The Portfolio Analysis features autism project and 
funding information for certain federal agencies and private 
organizations. According to officials within the National Institutes 
of Health Office of Autism Research Coordination (OARC), the agencies 
and organizations in these reports have been identified by the IACC 
and OARC as being involved in autism research and have agreed to 
participate. According to the IACC, the intent of these analysis 
reports is to better inform the IACC and interested stakeholders about 
the funding landscape for a particular year. Additionally, the 
analysis examines the extent to which a particular year's funding and 
research topics align with the IACC's most recent Strategic Plan. The 
IACC reports that the Portfolio Analysis may also be used by federal 
agencies and private research organizations to help guide future 
funding priorities by outlining current gaps and opportunities in 
autism research, as well as serving to highlight current activities 
and research progress. OARC officials told us that they plan to issue 
the 2011 report in 2013. 

Report: Summary of Advances in Autism Spectrum Disorder Research 
(2007, 2008, 2009, 2010, 2011); 
Description: Each year the IACC releases its list of scientific 
advances in autism research. As reported by the IACC, the report 
highlights studies on autism published in the previous year in peer-
reviewed journals and selected by members of the IACC. The number of 
studies featured over the years ranges from 20 to 54. The CAA requires 
that the IACC produce the Summary of Advances annually. 

Report: Autism Spectrum Disorder Research Publications Analysis: The 
Global Landscape of Autism Research[B]; Description: As reported by the 
IACC, this report describes several key aspects of worldwide autism 
research publications, which may be used to inform planning and 
strategic funding decisions for future autism research. Autism-related 
research articles published between 1980 and 2010 were analyzed to 
identify historical trends and publication outputs across the seven 
questions and research areas of the 2011 IACC Strategic Plan. 
Information found in research publications was also used to assess the 
institutions conducting autism research, funding organizations 
supporting the research publications, and the extent of collaboration 
between authors from different countries and research institutions. 
Additionally, measures, such as citation counts, were used as an 
assessment of the impact of the published research. OARC officials 
told us that there are no plans to update this report annually. 

Source: GAO review of IACC and OARC documents. 

[A] In 2008 and 2010, OARC, National Institute of Mental Health, 
prepared this report on behalf of the IACC. In 2009, OARC, National 
Institute of Mental Health, and Acclaro Research Solutions, Inc. 
prepared this report on behalf of the IACC. 

[B] OARC, National Institute of Mental Health, and Thomson Reuters, 
Inc. prepared this report on behalf of the IACC. 

[End of table] 

[End of section] 

Appendix III: Department of Health and Human Services (HHS) Funding 
for Autism Activities for Fiscal Years 2006 through 2011: 

Health Resources and Services Administration (HRSA); 
Fiscal year: 
2006: $20.0 million[A]; 
2007: $19.9 million[A]; 
2008: $36.4 million; 
2009: $42.0 million; 
2010: $47.9 million; 
2011: $47.7. 

National Institutes of Health (NIH); 
Fiscal year: 
2006: $108.3 million; 
2007: $126.8 million; 
2008: $118.1 million; 
2009: $196.4 million[B]; 
2010: $217.1 million[B]; 
2011: $168.7 million. 

Centers for Disease Control and Prevention (CDC); 
Fiscal year: 
2006: $15.1 million; 
2007: $14.8 million; 
2008: $16.2 million; 
2009: $20.4 million; 
2010: $22.1 million; 
2011: $21.4 million. 

Interagency Autism Coordinating Committee (IACC); 
Fiscal year: 
2006: $0.2 million; 
2007: $0.1 million; 
2008: $1.2 million; 
2009: $2.6 million; 
2010: $2.6 million; 
2011: $2.6 million. 

Total[C]; 
Fiscal year: 
2006: $143.6 million; 
2007: $161.6 million; 
2008: $171.8 million; 
2009: $261.4 million; 
2010: $289.7 million; 
2011: $240.4 million. 

Source: GAO analysis of HRSA, NIH, CDC, and IACC documents and 
interviews. 

Notes: While the Combating Autism Act (CAA) authorized appropriations 
for HRSA, NIH, CDC, and IACC autism activities, the CAA did not 
appropriate funds for this purpose. Instead, to fund these activities, 
HRSA, NIH, and CDC used funds appropriated to the agencies annually 
through the budget and appropriations process for the purpose of 
carrying out a variety of programs. As directed by Congress in the 
annual HHS appropriations acts for fiscal years 2008 through 2011, the 
Secretary of Health and Human Services transferred funds to NIH's 
National Institute of Mental Health (NIMH) for the IACC. The IACC also 
received funds from the annual NIH appropriation for fiscal years 2006 
through 2011. 

HRSA's totals include autism grant awards, as well as, for example, 
funding used for HRSA's personnel expenses, travel, supplies, and 
overhead related to reviewing these grants. NIH's totals include 
funding for research that is conducted outside of NIH's autism-
specific grant announcements. According to NIH officials, much of the 
autism research funded by NIH is done under general grant 
announcements soliciting biomedical research. IACC's totals for fiscal 
years 2008 through 2011 include funding for the Office of Autism 
Research Coordination within NIMH. 

In fiscal year 2008, certain agencies, including HHS agencies, were 
subject to an across-the-board rescission. All nondefense 
discretionary programs were subject to an across-the-board rescission 
in fiscal year 2011. According to HRSA officials, HRSA spent less on 
its autism activities in these years as a result of the rescissions. 
NIH officials told us that the agency reduced funding for research 
grants as a result of the rescissions, but could not measure the 
precise effect on autism-related grants. According to CDC officials, 
CDC spent less on its autism activities in fiscal year 2011 as a 
result of the rescission in that year. In addition, the IACC received 
less funding in fiscal years 2008 and 2011 as a result of the 
rescissions. 

[A] HRSA's fiscal year 2006 and 2007 funding represents total funding 
for its Leadership Education in Neurodevelopmental and Other Related 
Disabilities and Developmental-Behavioral Pediatrics training 
programs, through which the agency awarded grants that could have had 
an autism-specific component; however, an autism-specific component 
was not a requirement of the grants. Beginning in fiscal year 2008, 
these training programs were required to have an autism-specific 
component. 

[B] NIH's fiscal year 2009 and 2010 funding totals include additional 
funds appropriated to NIH under the American Recovery and Reinvestment 
Act of 2009. NIH spent $64 million of these funds in fiscal year 2009 
and $57.5 million in fiscal year 2010 on autism activities. 

[C] Individual funding entries may not sum to total due to rounding. 

[End of table] 

[End of section] 

Appendix IV: Combating Autism Act Grantees from Fiscal Years 2008 
through 2011 by Program: 

In fiscal year 2008, in response to the Combating Autism Act, the 
Health Resources and Services Administration (HRSA) created the 
Combating Autism Act Initiative. Under this initiative, HRSA has a 
number of programs that fund grants specific to autism. This appendix 
includes a description of the purpose of each program. Tables 3 
through 11 list the grants that have been awarded under each program 
for fiscal years 2008 through 2011.[Footnote 42] 

Program: Leadership Education in Neurodevelopmental and Other Related 
Disabilities (LEND) Training Program. The purpose of this program is 
to improve the health of children who have, or are at risk for 
developing, neurodevelopmental and other related disabilities by 
training professionals to assume leadership roles, and to ensure high 
levels of interdisciplinary clinical competence in an effort to 
increase diagnosis of or rule out individuals' developmental 
disabilities, including autism. 

Table 3: Leadership Education in Neurodevelopmental and Other Related 
Disabilities Training Program Grantees from Fiscal Years 2008 through 
2011: 

Grant number: T73MC00003; 
Grantee name: University of Alabama at Birmingham; 
Fiscal year 2008 award: $755,326; 
Fiscal year 2009 award: $755,326; 
Fiscal year 2010 award: $755,326; 
Fiscal year 2011 award: $680,758. 

Grant number: T73MC00008; 
Grantee name: Children's Hospital of Los Angeles, School of Physical 
Therapy; 
Fiscal year 2008 award: $818,784; 
Fiscal year 2009 award: $818,784; 
Fiscal year 2010 award: $818,785; 
Fiscal year 2011 award: $650,973. 

Grant number: T73MC00013; 
Grantee name: University of Miami; 
Fiscal year 2008 award: $629,576; 
Fiscal year 2009 award: $729,576; 
Fiscal year 2010 award: $814,576; 
Fiscal year 2011 award: $787,500[A]. 

Grant number: T73MC00014; 
Grantee name: University of Hawaii at Manoa; 
Fiscal year 2008 award: $495,166; 
Fiscal year 2009 award: $595,166; 
Fiscal year 2010 award: $670,166; 
Fiscal year 2011 award: $595,000. 

Grant number: T73MC00015; 
Grantee name: Indiana University, School of Medicine; 
Fiscal year 2008 award: $681,440; 
Fiscal year 2009 award: $681,440; 
Fiscal year 2010 award: $681,440; 
Fiscal year 2011 award: $632,046. 

Grant number: T73MC00016; 
Grantee name: University of Iowa; 
Fiscal year 2008 award: $491,265; 
Fiscal year 2009 award: $591,265; 
Fiscal year 2010 award: $666,265; 
Fiscal year 2011 award: $586,537. 

Grant number: T73MC00019; 
Grantee name: The Johns Hopkins University; 
Fiscal year 2008 award: $884,277; 
Fiscal year 2009 award: $35,840; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $0. 

Grant number: T73MC17245; 
Grantee name: Kennedy Krieger Children's Hospital, Inc.; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $948,416; 
Fiscal year 2010 award: $1,059,256; 
Fiscal year 2011 award: $850,000. 

Grant number: T73MC00020; 
Grantee name: Children's Hospital (Boston, MA); 
Fiscal year 2008 award: $755,326; 
Fiscal year 2009 award: $755,326; 
Fiscal year 2010 award: $755,326; 
Fiscal year 2011 award: $745,000[A]. 

Grant number: T73MC00022; 
Grantee name: Curators of University of Missouri at Columbia; 
Fiscal year 2008 award: $393,012; 
Fiscal year 2009 award: $493,012; 
Fiscal year 2010 award: $568,012; 
Fiscal year 2011 award: $574,811. 

Grant number: T73MC00023; 
Grantee name: Board of Regents of the University of Nebraska; 
Fiscal year 2008 award: $612,663; 
Fiscal year 2009 award: $612,663; 
Fiscal year 2010 award: $612,663; 
Fiscal year 2011 award: $622,943. 

Grant number: T73MC00024; 
Grantee name: Trustees of Dartmouth College; 
Fiscal year 2008 award: $651,964; 
Fiscal year 2009 award: $651,964; 
Fiscal year 2010 award: $651,964; 
Fiscal year 2011 award: $848,868. 

Grant number: T73MC00025; 
Grantee name: University of New Mexico Health Sciences Center; 
Fiscal year 2008 award: $527,560; 
Fiscal year 2009 award: $627,560; 
Fiscal year 2010 award: $702,560; 
Fiscal year 2011 award: $680,000. 

Grant number: T73MC00027; 
Grantee name: Albert Einstein College of Medicine; 
Fiscal year 2008 award: $691,265; 
Fiscal year 2009 award: $691,265; 
Fiscal year 2010 award: $691,265; 
Fiscal year 2011 award: $679,299. 

Grant number: T73MC00029; 
Grantee name: University of Rochester; 
Fiscal year 2008 award: $691,265; 
Fiscal year 2009 award: $691,265; 
Fiscal year 2010 award: $691,265; 
Fiscal year 2011 award: $684,028. 

Grant number: T73MC00030; 
Grantee name: University of North Carolina at Chapel Hill; 
Fiscal year 2008 award: $768,691; 
Fiscal year 2009 award: $768,691; 
Fiscal year 2010 award: $798,691; 
Fiscal year 2011 award: $910,004[A]. 

Grant number: T73MC00032; 
Grantee name: University of Cincinnati; 
Fiscal year 2008 award: $766,373; 
Fiscal year 2009 award: $866,373; 
Fiscal year 2010 award: $941,373; 
Fiscal year 2011 award: $800,167. 

Grant number: T73MC00033; 
Grantee name: University of Oklahoma HSC; 
Fiscal year 2008 award: $442,139; 
Fiscal year 2009 award: $542,139; 
Fiscal year 2010 award: $617,139; 
Fiscal year 2011 award: $595,000. 

Grant number: T73MC00034; 
Grantee name: Oregon Health & Sciences University; 
Fiscal year 2008 award: $685,979; 
Fiscal year 2009 award: $785,979; 
Fiscal year 2010 award: $860,979; 
Fiscal year 2011 award: $742,050. 

Grant number: T73MC00036; 
Grantee name: University of Pittsburgh; 
Fiscal year 2008 award: $393,012; 
Fiscal year 2009 award: $493,012; 
Fiscal year 2010 award: $568,012; 
Fiscal year 2011 award: $659,779[A]. 

Grant number: T73MC00037; 
Grantee name: University of South Dakota; 
Fiscal year 2008 award: $432,313; 
Fiscal year 2009 award: $532,313; 
Fiscal year 2010 award: $607,313; 
Fiscal year 2011 award: $602,466[A]. 

Grant number: T73MC00038; 
Grantee name: University of Tennessee at Knoxville; 
Fiscal year 2008 award: $953,109; 
Fiscal year 2009 award: $953,109; 
Fiscal year 2010 award: $953,459; 
Fiscal year 2011 award: $807,500[A]. 

Grant number: T73MC00039; 
Grantee name: University of Vermont; 
Fiscal year 2008 award: $651,964; 
Fiscal year 2009 award: $587,125; 
Fiscal year 2010 award: $651,964; 
Fiscal year 2011 award: $550,000. 

Grant number: T73MC00040; 
Grantee name: Virginia Commonwealth University; 
Fiscal year 2008 award: $451,964; 
Fiscal year 2009 award: $504,798; 
Fiscal year 2010 award: $626,964; 
Fiscal year 2011 award: $584,773. 

Grant number: T73MC00041; 
Grantee name: University of Washington; 
Fiscal year 2008 award: $940,435; 
Fiscal year 2009 award: $940,435; 
Fiscal year 2010 award: $940,435; 
Fiscal year 2011 award: $891,030[A]. 

Grant number: T73MC00043; 
Grantee name: West Virginia University Research Corporation; 
Fiscal year 2008 award: $639,822; 
Fiscal year 2009 award: $639,822; 
Fiscal year 2010 award: $639,822; 
Fiscal year 2011 award: $567,935. 

Grant number: T73MC00044; 
Grantee name: University of Wisconsin at Madison; 
Fiscal year 2008 award: $569,576; 
Fiscal year 2009 award: $669,576; 
Fiscal year 2010 award: $744,576; 
Fiscal year 2011 award: $738,483[A]. 

Grant number: T73MC00049; 
Grantee name: Ohio State University Research Foundation; 
Fiscal year 2008 award: $393,011; 
Fiscal year 2009 award: $493,011; 
Fiscal year 2010 award: $568,011; 
Fiscal year 2011 award: $821,027. 

Grant number: T73MC00050; 
Grantee name: Vanderbilt University Medical Center; 
Fiscal year 2008 award: $593,012; 
Fiscal year 2009 award: $593,012; 
Fiscal year 2010 award: $623,012; 
Fiscal year 2011 award: $651,500. 

Grant number: T73MC00051; 
Grantee name: The Children's Hospital of Philadelphia; 
Fiscal year 2008 award: $790,966; 
Fiscal year 2009 award: $784,966; 
Fiscal year 2010 award: $790,966; 
Fiscal year 2011 award: $764,391. 

Grant number: T73MC00054; 
Grantee name: University of Utah; 
Fiscal year 2008 award: $755,241; 
Fiscal year 2009 award: $755,241; 
Fiscal year 2010 award: $785,241; 
Fiscal year 2011 award: $823,048[A]. 

Grant number: T73MC00056; 
Grantee name: University of Massachusetts Medical School; 
Fiscal year 2008 award: $604,256; 
Fiscal year 2009 award: $704,256; 
Fiscal year 2010 award: $779,256; 
Fiscal year 2011 award: $685,732. 

Grant number: T73MC03181; 
Grantee name: Children's Research Institute (Washington, DC); 
Fiscal year 2008 award: $593,012; 
Fiscal year 2009 award: $593,012; 
Fiscal year 2010 award: $593,012; 
Fiscal year 2011 award: $0. 

Grant number: T73MC04320; 
Grantee name: New York Medical College; 
Fiscal year 2008 award: $620,597; 
Fiscal year 2009 award: $720,597; 
Fiscal year 2010 award: $795,597; 
Fiscal year 2011 award: $693,003. 

Grant number: T73MC06623; 
Grantee name: University of Kansas Medical Center Research Institute; 
Fiscal year 2008 award: $743,630; 
Fiscal year 2009 award: $743,630; 
Fiscal year 2010 award: $743,630; 
Fiscal year 2011 award: $641,760. 

Grant number: T73MC11044; 
Grantee name: University of Colorado at Denver; 
Fiscal year 2008 award: $550,000; 
Fiscal year 2009 award: $550,000; 
Fiscal year 2010 award: $550,000; 
Fiscal year 2011 award: $617,500[A]. 

Grant number: T73MC11045; 
Grantee name: University of Arkansas for Medical Sciences; 
Fiscal year 2008 award: $550,000; 
Fiscal year 2009 award: $549,999; 
Fiscal year 2010 award: $549,114; 
Fiscal year 2011 award: $757,995. 

Grant number: T73MC11046; 
Grantee name: University of Connecticut Health Center; 
Fiscal year 2008 award: $550,000; 
Fiscal year 2009 award: $550,000; 
Fiscal year 2010 award: $550,000; 
Fiscal year 2011 award: $0. 

Grant number: T73MC11047; 
Grantee name: University of Illinois at Chicago, College of Medicine; 
Fiscal year 2008 award: $549,999; 
Fiscal year 2009 award: $549,998; 
Fiscal year 2010 award: $550,000; 
Fiscal year 2011 award: $661,752. 

Grant number: T73MC12835; 
Grantee name: Regents of the University of Minnesota; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $450,000; 
Fiscal year 2010 award: $550,000; 
Fiscal year 2011 award: $627,616. 

Grant number: T73MC19939; 
Grantee name: Georgia State University Research Foundation, Inc.; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $150,000; 
Fiscal year 2011 award: $545,898. 

Grant number: T73MC19940; 
Grantee name: Board of Regents, Nevada System of Higher Education, on 
behalf of University of Nevada at Reno; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $150,000; 
Fiscal year 2011 award: $508,533. 

Grant number: T73MC20662; 
Grantee name: University of Arizona; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $150,000; 
Fiscal year 2011 award: $568,353. 

Grant number: T73MC20663; 
Grantee name: University of Alaska Anchorage; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $150,000; 
Fiscal year 2011 award: $530,039. 

Grant number: T73MC22233; 
Grantee name: Medical University of South Carolina; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $486,440. 

Grant number: T73MC22236; 
Grantee name: The University of Texas Health Science Center at Houston; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $509,748. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[A] Total funding in fiscal year 2011 includes $65,000 of supplemental 
funds that the grantee received from HRSA's Universal Newborn Hearing 
Screening program to support additional audiology trainees. 

[End of table] 

Program: Developmental-Behavioral Pediatrics (DBP) Training Program. 
The purpose of this program is to train the next generation of leaders 
in developmental-behavioral pediatrics; and provide pediatric 
practitioners, residents, and medical students with essential 
biopsychosocial knowledge and clinical expertise. This program is 
focused on developmental disabilities, including autism. 

Table 4: Developmental-Behavioral Pediatrics Training Program Grantees 
from Fiscal Years 2008 through 2011: 

Grant number: T77MC00004; 
Grantee name: Case Western Reserve University; 
Fiscal year 2008 Award: $192,467; 
Fiscal year 2009 Award: $192,467; 
Fiscal year 2010 Award: $192,467; 
Fiscal year 2011 Award: $192,453. 

Grant number: T77MC00009; 
Grantee name: Montefiore Medical Center; 
Fiscal year 2008 Award: $192,467; 
Fiscal year 2009 Award: $192,467; 
Fiscal year 2010 Award: $192,467; 
Fiscal year 2011 Award: $192,467. 

Grant number: T77MC00011; 
Grantee name: Children's Hospital (Boston, MA); 
Fiscal year 2008 Award: $192,467; 
Fiscal year 2009 Award: $192,467; 
Fiscal year 2010 Award: $192,467; 
Fiscal year 2011 Award: $192,467. 

Grant number: T77MC00012; 
Grantee name: The Children's Hospital of Philadelphia; 
Fiscal year 2008 Award: $229,048; 
Fiscal year 2009 Award: $191,943; 
Fiscal year 2010 Award: $191,944; 
Fiscal year 2011 Award: $191,943. 

Grant number: T77MC00015; 
Grantee name: Boston Medical Center; 
Fiscal year 2008 Award: $192,467; 
Fiscal year 2009 Award: $192,467; 
Fiscal year 2010 Award: $240,467; 
Fiscal year 2011 Award: $237,019. 

Grant number: T77MC00024; 
Grantee name: Yale University; 
Fiscal year 2008 Award: $209,605; 
Fiscal year 2009 Award: $222,467; 
Fiscal year 2010 Award: $192,467; 
Fiscal year 2011 Award: $192,467. 

Grant number: T77MC09796; 
Grantee name: Board of Trustees of the Leland Stanford Junior 
University; 
Fiscal year 2008 Award: $142,467; 
Fiscal year 2009 Award: $162,467; 
Fiscal year 2010 Award: $192,467; 
Fiscal year 2011 Award: $192,467. 

Grant number: T77MC09797; 
Grantee name: Rhode Island Hospital; 
Fiscal year 2008 Award: $142,467; 
Fiscal year 2009 Award: $142,467; 
Fiscal year 2010 Award: $192,467; 
Fiscal year 2011 Award: $222,467. 

Grant number: T77MC09798; 
Grantee name: University of Arkansas for Medical Sciences, Cancer 
Research Center; 
Fiscal year 2008 Award: $111,143; 
Fiscal year 2009 Award: $140,102; 
Fiscal year 2010 Award: $144,948; 
Fiscal year 2011 Award: $145,000. 

Grant number: T77MC09799; 
Grantee name: University of Oklahoma, Health Sciences Center; 
Fiscal year 2008 Award: $142,467; 
Fiscal year 2009 Award: $142,467; 
Fiscal year 2010 Award: $172,467; 
Fiscal year 2011 Award: $142,467. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[End of table] 

Program: National Combating Autism Interdisciplinary Training Resource 
Center. The purpose of this program is to improve the health of 
children who have, or are at risk for developing, autism and other 
developmental disabilities by providing technical assistance to LEND 
and DBP programs to better train professionals to utilize valid and 
reliable screening tools for diagnosing or ruling out autism, and 
provide evidence-based interventions for children. 

Table 5: National Combating Autism Interdisciplinary Training Resource 
Center Grantees from Fiscal Years 2008 through 2011: 

Grant number: UA5MC11068; 
Grantee name: Association of University Centers on Disabilities; 
Fiscal year 2008 award: $487,641; 
Fiscal year 2009 award: $547,641; 
Fiscal year 2010 award: $637,314; 
Fiscal year 2011 award: $784,641. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

Note: Funding in fiscal years 2010 and 2011 includes supplemental 
funds of $89,673 and $147,000, respectively, that the grantee received 
from HRSA's Universal Newborn Hearing Screening program to support 
audiology training within HRSA's Leadership Education in 
Neurodevelopmental and Other Related Disabilities training program. 

[End of table] 

Program: Autism Intervention Research Program and Autism Intervention 
Secondary Data Analysis Studies Program. The purpose of this program 
is to support research on evidence-based practices for interventions 
to improve the health and well-being of children and adolescents with 
autism and other developmental disabilities. The Autism Intervention 
Secondary Data Analysis Studies Program utilizes the analysis of 
existing secondary data. 

Table 6: Autism Intervention Research Program and Autism Intervention 
Secondary Data Analysis Studies Program Grantees from Fiscal Years 
2008 through 2011: 

Grant number: R40MC15593; 
Grantee name: University of Colorado at Denver; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $393,024; 
Fiscal year 2010 Award: $400,000; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC15594; 
Grantee name: Kennedy Krieger Institute, Inc.; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $393,024; 
Fiscal year 2010 Award: $400,000; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC15595; 
Grantee name: University of North Carolina at Chapel Hill; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $93,533; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC15596; 
Grantee name: Boston Medical Center; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $393,019; 
Fiscal year 2010 Award: $399,994; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC15597; 
Grantee name: University of New Hampshire; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $393,024; 
Fiscal year 2010 Award: $400,000; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC15598; 
Grantee name: Brandeis University; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $334,359; 
Fiscal year 2010 Award: $291,635; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC16396; 
Grantee name: University of Massachusetts at Boston; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $100,000; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC17158; 
Grantee name: University of North Carolina at Chapel Hill; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $100,000; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC17170; 
Grantee name: Georgia State University Research Foundation, Inc.; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $100,000; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC19925; 
Grantee name: The General Hospital Corporation; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $256,917; 
Fiscal year 2011 Award: $294,647. 

Grant number: R40MC19926; 
Grantee name: The Curators of the University of Missouri; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $184,288; 
Fiscal year 2011 Award: $188,378. 

Grant number: R40MC19927; 
Grantee name: Brandeis University; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $98,962; 
Fiscal year 2011 Award: $0. 

Grant number: R40MC19928; 
Grantee name: Boston Medical Center Corporation; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $299,906; 
Fiscal year 2011 Award: $298,072. 

Grant number: R40MC20171; 
Grantee name: Georgetown University; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $299,993; 
Fiscal year 2011 Award: $299,955. 

Grant number: R40MC20172; 
Grantee name: University of Connecticut Health Center; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $300,000; 
Fiscal year 2011 Award: $300,000. 

Grant number: R40MC20444; 
Grantee name: West Virginia University Research Corporation; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $296,372; 
Fiscal year 2011 Award: $296,146. 

Grant number: R40MC20611; 
Grantee name: Health Research, Inc./New York State Department of 
Health; 
Fiscal year 2008 Award: $0: 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $300,000; 
Fiscal year 2011 Award: $300,000. 

Grant number: R40MC22641; 
Grantee name: Regents of the University of California; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $285,177. 

Grant number: R40MC22642; 
Grantee name: Regents of the University of California; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $99,988. 

Grant number: R40MC22643; 
Grantee name: University of Colorado at Denver; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $300,000. 

Grant number: R40MC22644; 
Grantee name: University of Iowa; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $299,972. 

Grant number: R40MC22645; 
Grantee name: University of Massachusetts; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $300,000. 

Grant number: R40MC22646; 
Grantee name: University of Massachusetts at Boston; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $100,000. 

Grant number: R40MC22647; 
Grantee name: University of North Carolina at Chapel Hill; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $100,000. 

Grant number: R40MC22648; 
Grantee name: University of North Carolina at Chapel Hill; 
Fiscal year 2008 Award: $0; 
Fiscal year 2009 Award: $0; 
Fiscal year 2010 Award: $0; 
Fiscal year 2011 Award: $299,997. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[End of table] 

Program: Autism Intervention Research Network on Physical Health. The 
purpose of this program is to establish and maintain a network 
infrastructure designed to be the platform from which to conduct 
research on evidence-based practices for interventions to improve the 
physical health and well-being of individuals with autism and other 
developmental disabilities; develop evidence-based guidelines and 
validate tools for interventions; and disseminate critical information 
on its research findings, guidelines, and tools. 

Table 7: Autism Intervention Research Network on Physical Health 
Grantees from Fiscal Years 2008 through 2011: 

Grant number: UA3MC11054; 
Grantee name: The General Hospital Corporation; 
Fiscal year 2008 award: $3,999,342; 
Fiscal year 2009 award: $3,997,824; 
Fiscal year 2010 award: $3,651,425; 
Fiscal year 2011 award: $3,999,847. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[End of table] 

Program: Autism Intervention Research Network on Behavioral Health. 
The purpose of this program is to establish and maintain a network 
infrastructure designed to be the platform from which to conduct 
research on evidence-based interventions to improve the behavioral, 
mental, social, or cognitive health, or a mix of those, and well-being 
of children and adolescents with autism and other developmental 
disabilities; develop evidence-based guidelines and validate tools for 
interventions; and disseminate critical information on its research 
findings, guidelines, and tools. 

Table 8: Autism Intervention Research Network on Behavioral Health 
Grantees from Fiscal Years 2008 through 2011: 

Grant number: UA3MC11055; 
Grantee name: Regents of the University of California; 
Fiscal year 2008 award: $2,000,000; 
Fiscal year 2009 award: $1,930,288; 
Fiscal year 2010 award: $1,989,276; 
Fiscal year 2011 award: $2,000,000. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[End of table] 

Program: Developmental-Behavioral Pediatrics Research Network. The 
purpose of this program is to establish a multicenter scientific and 
clinical research network that will promote coordinated research 
activities and address health issues. The program is intended to build 
a developmental behavioral pediatric research infrastructure that 
supports multidisciplinary research, focuses on the translation of 
research to practice, and provides the environment in which to train a 
new generation of developmental behavioral pediatric researchers. 

Table 9: Developmental-Behavioral Pediatrics Research Network Grantees 
from Fiscal Years 2008 through 2011: 

Grant number: UA3MC20218; 
Grantee name: The Children's Hospital of Philadelphia; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $200,000; 
Fiscal year 2011 award: $220,000. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[End of table] 

Program: State Implementation and Planning Grants. The purpose of this 
program is to improve access to comprehensive, coordinated health care 
and related services by implementing state plans to improve the system 
of services.[Footnote 43] 

Table 10: State Implementation and Planning Grants Grantees from 
Fiscal Years 2008 through 2011: 

Grant number: H6MMC11059a; 
Grantee name: The Curators of the University of Missouri; 
Fiscal year 2008 award: $297,957; 
Fiscal year 2009 award: $295,703; 
Fiscal year 2010 award: $467,729; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC11061a; 
Grantee name: Utah Department of Health; 
Fiscal year 2008 award: $300,000; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $497,757; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC11062; 
Grantee name: The Hope School (Springfield, IL); 
Fiscal year 2008 award: $300,000; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $300,000; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC11063; 
Grantee name: Wisconsin Department of Health & Family Services; 
Fiscal year 2008 award: $300,000; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $300,000; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC11064a; 
Grantee name: State of Alaska, Department of Health & Social Services; 
Fiscal year 2008 award: $300,000; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $497,757; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC11065a; 
Grantee name: State of Washington Department of Health; 
Fiscal year 2008 award: $300,000; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $497,757; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC15102; 
Grantee name: Rhode Island Department of Health; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $300,000; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC15103; 
Grantee name: University of New Mexico Health Sciences Center; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $300,000; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC15104; 
Grantee name: Health Research, Inc./New York State Department of 
Health; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $300,000; 
Fiscal year 2010 award: $300,000; 
Fiscal year 2011 award: $0. 

Grant number: H6MMC20326; 
Grantee name: Vermont State Department of Health; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $272,463; 
Fiscal year 2011 award: $300,000. 

Grant number: H6MMC20327; 
Grantee name: Hawaii Pediatric Association Research & Education 
Foundation; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $272,463; 
Fiscal year 2011 award: $300,000. 

Grant number: H6MMC20328; 
Grantee name: Statewide Parent Advocacy Network of New Jersey; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $272,463; 
Fiscal year 2011 award: $300,000. 

Grant number: H6MMC20329; 
Grantee name: Maine Department of Health and Human Services; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $272,463; 
Fiscal year 2011 award: $300,000. 

Grant number: H6MMC22710; 
Grantee name: Georgia State University Research Foundation; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $75,000. 

Grant number: H6MMC22711; 
Grantee name: Tennessee Disability Coalition; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $75,000. 

Grant number: H6MMC22712; 
Grantee name: The Parents' Place of Maryland; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $75,000. 

Grant number: H6MMC22713; 
Grantee name: University of Delaware; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $74,999. 

Grant number: H6MMC22737; 
Grantee name: Autism Society of Colorado; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $243,092. 

Grant number: H6MMC22738; 
Grantee name: Connecticut Department of Public Health; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $243,092. 

Grant number: H6MMC22739; 
Grantee name: Minot State University; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $243,092. 

Grant number: H6MMC22740; 
Grantee name: University of Southern Mississippi; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $243,092. 

Grant number: H6MMC22849; 
Grantee name: Ohio Department of Developmental Disabilities; 
Fiscal year 2008 award: $0; 
Fiscal year 2009 award: $0; 
Fiscal year 2010 award: $0; 
Fiscal year 2011 award: $243,092. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[A] Totals for this grantee in fiscal year 2010 include supplemental 
funding to expand its implementation of the Centers for Disease 
Control and Prevention's (CDC) Learn the Signs. Act Early. campaign. 
This supplement is funded through an interagency agreement between 
HRSA and CDC. 

[End of table] 

Program: State Public Health Coordinating Center. The program purpose 
is to improve the health of children who have, or are at risk for 
developing, autism and other developmental disabilities by 
coordinating with the state demonstration grantees; and by developing 
a strategy for defining, supporting, and monitoring the role of state 
public health agencies in assuring early and timely identification, 
diagnosis, and intervention. 

Table 11: State Public Health Coordinating Center Grantees from Fiscal 
Years 2008 through 2011: 

Grant number: U01MC11069; 
Grantee name: Association of Maternal & Child Health Programs; 
Fiscal year 2008 award: $250,000; 
Fiscal year 2009 award: $250,000; 
Fiscal year 2010 award: $275,000; 
Fiscal year 2011 award: $275,000. 

Source: GAO analysis of Health Resources and Services Administration 
(HRSA) information. 

[End of table] 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Marcia Crosse, (202) 512-7114 or crossem@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Geri Redican-Bigott, Assistant 
Director; Katherine L. Amoroso; George Bogart; Deirdre Brown; Sandra 
George; Cathleen Hamann; Kristin Helfer Koester; Drew Long; and Sarah 
Resavy made key contributions to this report. 

[End of section] 

Footnotes: 

[1] CDC's most recent estimates are based on data collected in 14 
areas of the United States. CDC's estimate of autism prevalence in 
2012 is based on data from calendar year 2008, and the 2009 estimate 
is based on data from calendar year 2006. 

[2] In this report, we use the term "autism" to refer to autism 
spectrum disorders. 

[3] Pub. L. No. 109-416, 120 Stat. 2821 (Dec. 19, 2006). 

[4] These activities were reauthorized and additional funding was 
authorized through fiscal year 2014 under the Combating Autism 
Reauthorization Act of 2011. Pub. L. No. 111-32, 125 Stat. 361 (Sept. 
30, 2011). 

[5] A subsequent report will examine the involvement of federal 
agencies in autism activities and the coordination of these activities. 

[6] HRSA was included in the review because the CAA requires the 
Secretary of Health and Human Services to establish various autism 
activities, and HRSA carries out these activities. 

[7] This guidance includes: HHS, Awarding Agency Grants Administration 
Manual (2007); HHS, Grants Policy Statement (2007); and HRSA, Office 
of Federal Assistance Management, Division of Grants Management 
Operations, Operational & Procedures Manual (2009). 

[8] Our sample is too small to generalize the results to the 110 CAA 
grantees as a whole; however, our sample is representative of the 
population of CAA grantees. 

[9] Agency staff use the EHB to award grants, review information 
related to CAA grants, and monitor CAA grantees' performance. Grantees 
upload information pertaining to their grant--such as required reports-
-and agency staff can indicate their review and approval of this 
information, in the EHB. While the submission of performance reports--
a report grantees submit annually with performance and budget 
information--is documented in the EHB, it is not possible to view 
these reports in the EHB. These reports can be viewed in the 
Discretionary Grant Information System--a system that regularly 
collects program and performance measure data, including performance 
reports, submitted by grantees. We reviewed files relating to grants 
awarded in fiscal years 2008 through 2011 that were included in these 
two data systems as of early October 2012. 

[10] A developmental disability is a chronic condition caused by 
mental impairment, physical impairment, or both that begins any time 
during prenatal development up to age 22 and usually persists 
throughout a person's life. Individuals with developmental 
disabilities have substantial functional limitations in at least three 
major life activities such as language, mobility, learning, self-help, 
and independent living. Developmental disabilities may include 
cerebral palsy, hearing loss, intellectual disability, and vision 
impairment. 

[11] A cooperative agreement is an alternative assistance instrument 
used instead of a grant whenever substantial federal involvement with 
the recipient during performance is anticipated. 

[12] Pub. L. No. 106-310, 114 Stat. 1101 (Oct. 17, 2000). We 
previously reported on federal autism activities under the Children's 
Health Act. See GAO, Federal Autism Activities: Funding for Research 
Has Increased, but Agencies Need to Resolve Surveillance Challenges, 
[hyperlink, http://www.gao.gov/products/GAO-06-700] (Washington, D.C.: 
July 19, 2006). 

[13] The CAA directs the Secretary of Health and Human Services to 
undertake autism education, early detection, and intervention 
activities, subject to the availability of federal funding; and HRSA 
and CDC carry out these activities. The CAA directives are: provide 
information and education on autism and other developmental 
disabilities to increase public awareness of developmental milestones; 
promote research into the development and validation of reliable 
screening tools for autism and other developmental disabilities, and 
disseminate information regarding those screening tools; promote early 
screening of individuals at higher risk for autism and other 
developmental disabilities as early as practicable, given evidence-
based screening techniques and interventions; increase the number of 
individuals who are able to confirm or rule out a diagnosis of autism 
and other developmental disabilities; increase the number of 
individuals able to provide evidence-based interventions for 
individuals diagnosed with autism or other developmental disabilities; 
and, promote the use of evidence-based interventions for individuals 
at higher risk for autism and other developmental disabilities as 
early as practicable. 

[14] HRSA spent approximately $19.9 million on the LEND and DBP 
training programs in fiscal year 2007. In fiscal year 2008, when the 
Combating Autism Act Initiative was implemented, HRSA spent 
approximately $25.8 million on the LEND and DBP training programs. 

[15] The states that received state implementation and planning grants 
are Alaska, Colorado, Connecticut, Delaware, Georgia, Hawaii, 
Illinois, Maine, Maryland, Mississippi, Missouri, New Jersey, New 
Mexico, New York, North Dakota, Ohio, Rhode Island, Tennessee, Utah, 
Vermont, Washington, and Wisconsin. 

[16] In contrast to the requirement contained in the Children's Health 
Act, however, the CAA directs NIH and CDC to undertake these 
activities subject to the availability of appropriations. 

[17] See, for example, Public Health Service Act, § 301 (codified at 
42 U.S.C. § 241) (providing NIH broad authority to award grants to 
public and private institutions to conduct scientific research). 

[18] The CAA specified that the IACC include certain federal members, 
such as officials from CDC, NIH, and the Department of Education. It 
also required the Secretary to appoint a minimum number of nonfederal 
members, which must include at least one person with autism; at least 
one parent or legal guardian of a person with autism; and at least one 
representative of a leading research, advocacy, or service 
organization for individuals with autism. The Children's Health Act 
did not require that nonfederal entities or officials from the 
Department of Education be included as IACC members. However, the 
Children's Health Act authorized the Secretary of Health and Human 
Services to appoint parents or legal guardians of individuals with 
autism to the committee. Prior to the enactment of the CAA, the 
committee included four nonfederal members. 

[19] The CAA also requires the IACC to make recommendations to the 
Secretary of Health and Human Services on any changes to federal 
activities, including recommendations made in the strategic plan on 
autism research. 

[20] Prior to the CAA, the IACC produced a research matrix that NIH 
officials viewed as a comprehensive list of autism research goals. It 
also issued an autism roadmap that provided a synthesis of issues and 
challenges related to services for individuals with autism and a set 
of performance measures and recommendations for improving services. 

[21] In addition, on behalf of the Secretary of Health and Human 
Services, OARC produced a report to Congress on autism activities as 
required by the CAA. See HHS, OARC, NIH, Report to Congress on 
Activities Related to Autism Spectrum Disorder and Other Developmental 
Disabilities Under the Combating Autism Act of 2006 (FY 2006 - FY 
2009) (Rockville, Md.: December 2010, revised April 2011). 

[22] While the CAA authorized appropriations for HRSA, NIH, and CDC 
autism activities, the CAA did not appropriate funds for this purpose. 
Instead, to fund these activities, HRSA, NIH, and CDC used funds 
appropriated to the agencies annually through the budget and 
appropriations process for the purpose of carrying out a variety of 
programs. 

[23] In fiscal year 2008, certain agencies, including HHS agencies, 
were subject to an across-the-board rescission. All nondefense 
discretionary programs were subject to an across-the-board rescission 
in fiscal year 2011. According to HRSA officials, HRSA spent less on 
its autism activities in these years as a result of the rescissions. 
NIH officials told us that the agency reduced funding for research 
grants as a result of the rescissions, but could not measure the 
precise effect on autism-related grants. According to CDC officials, 
CDC spent less on its autism activities in fiscal year 2011 as a 
result of the rescission in that year. In addition, the IACC received 
less funding in fiscal years 2008 and 2011 as a result of the 
rescissions. 

[24] HRSA issued these grants as part of its Combating Autism Act 
Initiative. For the purpose of this report we are referring to the 
programs and grantees in HRSA's Combating Autism Act Initiative as CAA 
grantees or CAA programs. 

[25] The annual federal financial reports were formerly called 
financial status reports. A budget period is the interval of time 
(usually 12 months each) into which a project period is divided for 
budgetary and funding purposes. The project period refers to the total 
period for which support of a project has been programmatically 
approved. 

[26] Grantees who submit a competing continuation application include 
a progress report summarizing progress made over the entire previous 
project period along with their application. Grantees who do not 
reapply for a grant, and complete the period of project support from 
HRSA, must submit a comprehensive final report. This report covers the 
last year of the project period and includes information on progress 
over all years of the project period. 

[27] HRSA started requiring mid-project reports of grantees in its 
Autism Intervention Research and Autism Intervention Secondary Data 
Analysis Studies Programs in fiscal year 2010. Because Autism 
Intervention Secondary Data Analysis Studies Program grants are 1-year 
grants, the reports are referred to as mid-year progress reports. 

[28] The research networks are the Autism Intervention Research 
Network on Physical Health, Autism Intervention Research Network on 
Behavioral Health, and Developmental-Behavioral Pediatric Research 
Network. 

[29] Progress reports that are submitted as part of competing 
continuation applications are reviewed with the application. HRSA 
staff use a checklist when reviewing the application. 

[30] HRSA grantees request funds that they have available at any time 
during the budget period through the use of an online form that is 
submitted to the HRSA Payment Management System. The Payment 
Management System keeps track of how often and what amount of funds 
are withdrawn by the grantee during the course of the budget period. 

[31] Our unbiased random sample of 22 grantees consisted of 11 
training grantees, 7 research grantees, and 4 state implementation and 
planning grantees. This sample is representative of the 110 CAA 
grantees. The grantees in our sample received about $28 million--about 
17 percent--of the total awards CAA grantees received from fiscal 
years 2008 through 2011. HRSA officials stated that no CAA grantees 
were high-risk grantees, and we found this to be accurate for the 
grantees we reviewed. "High risk" is used to describe a grantee that 
is at risk of financial failure or failure to perform based on a 
history of poor performance or poor business practices, financial 
instability, or inadequate management systems. 

[32] This includes 46 federal financial reports, 54 progress reports, 
4 mid-project progress reports, and 2 comprehensive final reports. 
This count includes one annual federal financial report per grantee 
per year. Grantees are allowed to revise and resubmit their federal 
financial report if they find that information needs to be corrected. 

[33] The question in the checklist is: "Are there any areas of 
concern: programmatic, budgetary, or other?" 

[34] In one instance, the grantee had not yet submitted the revised 
report at the time of our review. 

[35] The notice of award is the official document that states the 
terms, conditions, and amount of a grant award and is signed by the 
official who is authorized to obligate funds on behalf of HRSA. A 
notice of award shows the amount of federal funds available to the 
grantee and is issued at the start of each budget period. A revised 
notice of award may be issued during a budget period to effect an 
action resulting in a change in the amount of support or other change 
in the terms and conditions of award, such as a carryover of funds. 

[36] According to HRSA officials, HRSA staff began using a checklist 
to indicate their review and approval of prior-approval requests at 
the end of calendar year 2009. Prior to this, the issuance of a new 
notice of award indicated HRSA review and approval of such requests. 
We reviewed one carryover request related to an award in fiscal year 
2010 that did not have a review checklist in the EHB; however, a new 
notice of award indicated that the carryover request had been approved. 

[37] Grantees in HRSA's Autism Intervention Research and Autism 
Intervention Secondary Data Analysis Studies Programs are required to 
have a web-based site visit at project end. 

[38] Performance reports include financial forms, project abstracts 
and other grant summary data, and performance measures. Grantees 
submit initial performance reports at the beginning of the project 
period, annual performance reports after the end of each budget year, 
and project period end performance reports after the end of the 
project period. 

[39] HRSA expects to submit this report to Congress in the middle of 
calendar year 2013. 

[40] HRSA, Maternal and Child Health Bureau, Operations Manual, 
Combating Autism Act Initiative (Rockville, Md.: December 2012). 

[41] HHS guidance indicates that a program-wide approach to monitoring 
grantees must be established and reviewed at least annually to 
determine if the approach needs to be modified. This annual review 
should be documented, as appropriate, in the program information file. 
HHS, Awarding Agency Grants Administration Manual. 

[42] The fiscal years in tables 3 through 11 are based on the start 
date of the budget period for which the grant was awarded. The budget 
period for some of these grantees is from July 1 through June 31, and 
the budget period for other grantees is from September 1 through 
August 31. Under its Combating Autism Act Initiative, HRSA also 
provided supplemental funding to two existing cooperative agreements. 
A cooperative agreement is an alternative assistance instrument used 
instead of a grant whenever substantial federal involvement with the 
recipient during performance is anticipated. The first supplement is 
to provide technical assistance to grantees under one of HRSA's 
Combating Autism Act Initiative Programs--Leadership Education in 
Neurodevelopmental and Other Related Disabilities. The grantee is 
Georgetown University in Washington, D.C., and the grantee received 
$22,000 and $43,550 in fiscal years 2010 and 2011, respectively. The 
second supplement is to examine current knowledge, research gaps, and 
methodological challenges about the life-course trajectory of 
individuals with autism, and develop a life-course-focused autism 
research agenda. The grantee is the Regents of the University of 
California at Los Angeles and the grantee received $30,785 in fiscal 
year 2011. 

[43] This program comprises: State Implementation Grants for Improving 
Services for Children and Youth with Autism Spectrum Disorder and 
other Developmental Disabilities, and State Planning Grants for 
Improving Services for Children and Youth with Autism Spectrum 
Disorder and other Developmental Disabilities. 

[End of section] 

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