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McNally Keehn R, Penner M, Shannon J, Sohl K, Weitzman C, Zuckerman KE. Considerations and Actionable Steps to Promote Scaling of Early Autism Diagnosis in Community Primary Care Practice. J Dev Behav Pediatr 2024:00004703-990000000-00189. [PMID: 38996205 DOI: 10.1097/dbp.0000000000001297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/10/2024] [Indexed: 07/14/2024]
Affiliation(s)
| | - Melanie Penner
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Kristin Sohl
- Department of Pediatrics, School of Medicine, University of Missouri, Columbia, MO
| | - Carol Weitzman
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA; and
| | - Katharine E Zuckerman
- Department of Pediatrics, School of Medicine, Oregon Health & Science University, Portland, OR
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Wieckowski AT, Robins DL. Community testing practices prompt the rethinking of gold standard autism assessment. Paediatr Perinat Epidemiol 2024; 38:432-434. [PMID: 38772728 DOI: 10.1111/ppe.13095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/12/2024] [Indexed: 05/23/2024]
Affiliation(s)
| | - Diana L Robins
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
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Habayeb S, Inge A, Eisenman E, Godovich S, Lauer M, Hastings A, Fuentes V, Long M, Marshall X, Khuu A, Godoy L. Short report: Integrated evaluations for autism spectrum disorder in pediatric primary care clinics. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024:13623613241260800. [PMID: 38907720 DOI: 10.1177/13623613241260800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
LAY ABSTRACT Primary care providers often screen for autism during well child visits in the first few years of life and refer children for diagnostic evaluations when needed. However, most children do not receive a diagnosis until years later which delays access to services. Racism, socioeconomic status, and other systemic inequalities that limit access to health care further delay diagnostic evaluations. Mental health clinicians who work in primary care clinics can help address barriers to accessing diagnostic evaluation services once they are recommended by their primary care provider. However, mental health clinicians who work in primary care typically do not have training in diagnosing autism. The goal of this study was to evaluate a program training mental health professionals working in an urban primary care setting, primarily serving Black and Latinx families insured by Medicaid, to provide autism diagnostic evaluations. Two hundred and fifty children completed evaluations through the Autism in Primary Care (APC) program. The wait time to access an evaluation through APC was significantly shorter than through standard avenues of care (e.g. referring to a separate autism clinic). Referring primary care providers and caregivers endorsed high levels of satisfaction with the program. Conducting autism evaluations in primary care settings offers a promising opportunity to improve earlier diagnosis and treatment access for families, reduce inequities in care, and increase caregiver and child well-being.
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Wieckowski AT, Ramsey RK, Coulter K, Eldeeb SY, Algur Y, Ryan V, Stahmer AC, Robins DL. Role of Primary Care Clinician Concern During Screening for Early Identification of Autism. J Dev Behav Pediatr 2024; 45:e187-e194. [PMID: 38564788 PMCID: PMC11192612 DOI: 10.1097/dbp.0000000000001262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/22/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the added value of primary care clinician (PCC)-indicated concern during primary care universal standardized screening in early identification of autism. METHODS Toddlers were screened for autism during primary care checkups (n = 7,039, aged 14.24-22.43 months) in 2 studies. Parents completed the Modified Checklist for Autism in Toddlers, Revised, with Follow-Up. For each participant, PCCs indicated whether they had autism concerns (optional in 1 study-before or after viewing screening results, required before viewing screen results in the other). Children at high likelihood for autism from screen result and/or PCC concern (n = 615) were invited for a diagnostic evaluation; 283 children attended the evaluation. RESULTS Rates of PCC-indicated autism concerns were similar whether PCCs were required or encouraged to indicate concerns. High likelihood of autism indication on both screen and PCC concern resulted in the highest positive predictive value for autism and positive predictive value for any developmental disorder, as well as the highest evaluation attendance, with no significant difference between the positive screen-only and PCC concern-only groups. Although the frequency of PCC-indicated autism concern did not differ significantly based on the child's cognitive level, PCCs were more likely to identify children with more obvious autism characteristics compared with more subtle autism characteristics as having autism. CONCLUSION The findings support the recommendation of the American Academy of Pediatrics that both screening and surveillance for autism be incorporated into well-child visits. High likelihood of autism on either screen or PCC concern should trigger a referral for an evaluation.
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Affiliation(s)
| | | | - Kirsty Coulter
- Department of Psychological Sciences, University of Connecticut, Storrs, CT
| | | | - Yasemin Algur
- Department of Epidemiology & Biostatistics, Drexel University, Philadelphia, PA
| | - Victoria Ryan
- Department of Epidemiology & Biostatistics, Drexel University, Philadelphia, PA
| | - Aubyn C. Stahmer
- Department of Psychiatry and Behavioral Sciences, University of California, Davis MIND Institute, Sacramento, CA
| | - Diana L. Robins
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA
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Smith JV, Menezes M, Brunt S, Pappagianopoulos J, Sadikova E, O Mazurek M. Understanding autism diagnosis in primary care: Rates of diagnosis from 2004 to 2019 and child age at diagnosis. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024:13623613241236112. [PMID: 38456360 DOI: 10.1177/13623613241236112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
LAY ABSTRACT The current demand for autism diagnostic services exceeds the ability of the workforce to assess and diagnose children in a timely manner. One solution may be to equip primary care providers (PCPs) with the tools and expertise needed to diagnose autism within their practice. PCPs are often trusted professionals who have many touchpoints with children during early development, in which they can identify early signs of autism. Recent initiatives have focused on bolstering PCPs' diagnostic capabilities; however, no studies have examined how the rates of autism diagnosis in primary care have changed over time. We aimed to evaluate whether autism diagnosis in primary care has changed over time and how diagnosis in primary care relates to a child's age at the time of diagnosis. We found that the likelihood of a child being diagnosed by a PCP decreased by about 2% with every passing year from 2004 to 2019 when accounting for demographic characteristics. In our sample, PCPs diagnosed children approximately 1 year earlier than non-PCPs (e.g., psychologists and psychiatrists). Further research is needed to understand why the proportion of children diagnosed by PCPs decreases over time. However, this decrease suggests more work is needed to get capacity-building initiatives into community primary care practice. Though we must continue to find effective ways to build community PCPs' ability to diagnose autism, the present findings support the crucial role PCPs can play in early autism diagnosis.
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Affiliation(s)
- Jessica V Smith
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Michelle Menezes
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Sophie Brunt
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Jessica Pappagianopoulos
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Eleonora Sadikova
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Micah O Mazurek
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
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Thomas RP, de Marchena A, Wieckowski AT, Stahmer A, Milan S, Burke JD, Barton ML, Robins DL, Fein DA. Accuracy of initial diagnostic impressions of autism in toddlers and behaviors that inform these impressions. Autism Res 2024; 17:568-583. [PMID: 38216522 PMCID: PMC11025624 DOI: 10.1002/aur.3088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/09/2023] [Indexed: 01/14/2024]
Abstract
Clinicians form initial impressions about a child's diagnosis based on behavioral features, but research has not yet identified specific behaviors to guide initial diagnostic impressions. Participants were toddlers (N = 55, mean age 22.9 months) from a multi-site early detection study, referred for concern for ASD due to screening or parent/provider concern. Within 5 min of meeting a child, clinicians noted ASD or non-ASD impression, confidence in impression, and behaviors that informed their impression. These clinicians also determined final diagnoses for each child. When a child's final diagnosis was ASD (n = 35), senior clinicians formed an initial impression of ASD in 22 cases (63%) but missed 13 cases (37%). When final diagnosis was non-ASD (n = 20), senior clinicians made an initial impression of non-ASD in all cases (100%). Results were similar among junior clinicians. Senior and junior clinicians used the same behaviors to form accurate impressions of ASD and non-ASD: social reciprocity, nonverbal communication, and eye contact. Senior clinicians additionally used focus of attention when forming accurate impressions of ASD and non-ASD; junior clinicians used this behavior only when forming accurate non-ASD impressions. Clinicians' initial impressions of ASD are very likely to be consistent with final diagnoses, but initial impressions of non-ASD need follow-up. Toddlers who show all four atypical behaviors (social reciprocity, nonverbal communication, eye contact, and focus of attention) might receive expedited ASD diagnoses. However, presence of apparently typical behaviors should not rule out ASD; for some children a longer evaluation is necessary to allow for more opportunities to observe subtle social behavior.
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Affiliation(s)
- Rebecca P. Thomas
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut
| | - Ashley de Marchena
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | | | - Aubyn Stahmer
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, MIND Institute, Sacramento, California
| | - Stephanie Milan
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut
| | - Jeffrey D. Burke
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut
| | - Marianne L. Barton
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut
| | - Diana L. Robins
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | - Deborah A. Fein
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut
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O’Hagan B, Augustyn M, Amgott R, White J, Hardesty I, Bangham C, Ursitti A, Foster S, Chandler A, Greece J. Using normalization process theory to inform practice: evaluation of a virtual autism training for clinicians. FRONTIERS IN HEALTH SERVICES 2023; 3:1242908. [PMID: 38192729 PMCID: PMC10773704 DOI: 10.3389/frhs.2023.1242908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024]
Abstract
Background There is growing demand for developmental and behavioral pediatric services including autism evaluation and care management. Clinician trainings have been found to result in an increase of knowledge and attitudes. This study utilizes Normalization Process theory (NPT) to evaluate a clinician training program and its effects on practice. Methods The year-long virtual training program about autism screening and care management included didactic portions and case presentations. Focus groups and interviews were conducted with primary care clinicians (n = 10) from community health centers (n = 6) across an urban area five months post-training. Transcripts were deductively coded using NPT to uncover barriers to implementation of autism screening and care, benefits of the training program, and areas for future training. Results Participants were motivated by the benefits of expanding and improving support for autistic patients but noted this effort requires effective collaboration within a complex network of care providers including clinicians, insurance agencies, and therapy providers. Although there were support that participants could provide to families there were still barriers including availability of behavior therapy and insufficient staffing. Overall, participants positively viewed the training and reported implementing new strategies into practice. Conclusion Despite the small sample size, application of NPT allowed for assessment of both training delivery and implementation of strategies, and identification of recommendations for future training and practice sustainability. Follow-up focus groups explored participants' practice five months post-program. Variations in participants' baseline experience and context at follow-up to enable application of skills should be considered when using NPT to evaluate clinician trainings.
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Affiliation(s)
- Belinda O’Hagan
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Marilyn Augustyn
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Rachel Amgott
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Julie White
- Center for Continuing Education, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Ilana Hardesty
- Center for Continuing Education, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Candice Bangham
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States
| | - Amy Ursitti
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Sarah Foster
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Alana Chandler
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Jacey Greece
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States
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Hyman SL, Kroening ALH. Diagnosing Autism Spectrum Disorders in Primary Care: When You Know, You Know. Pediatrics 2023; 152:e2023062279. [PMID: 37461878 DOI: 10.1542/peds.2023-062279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 08/02/2023] Open
Affiliation(s)
- Susan L Hyman
- Golisano Children's Hospital, University of Rochester
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Keehn RM, Swigonski N, Enneking B, Ryan T, Monahan P, Martin AM, Hamrick L, Kadlaskar G, Paxton A, Ciccarelli M, Keehn B. Diagnostic Accuracy of Primary Care Clinicians Across a Statewide System of Autism Evaluation. Pediatrics 2023; 152:e2023061188. [PMID: 37461867 PMCID: PMC10686684 DOI: 10.1542/peds.2023-061188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of the Early Autism Evaluation (EAE) Hub system, a statewide network that provides specialized training and collaborative support to community primary care providers in the diagnosis of young children at risk for autism spectrum disorder (ASD). METHODS EAE Hub clinicians referred children, aged 14 to 48 months, to this prospective diagnostic study for blinded follow-up expert evaluation including assessment of developmental level, adaptive behavior, and ASD symptom severity. The primary outcome was agreement on categorical ASD diagnosis between EAE Hub clinician (index diagnosis) and ASD expert (reference standard). RESULTS Among 126 children (mean age: 2.6 years; 77% male; 14% Latinx; 66% non-Latinx white), 82% (n = 103) had consistent ASD outcomes between the index and reference evaluation. Sensitivity was 81.5%, specificity was 82.4%, positive predictive value was 92.6%, and negative predictive value was 62.2%. There was no difference in accuracy by EAE Hub clinician or site. Across measures of development, there were significant differences between true positive and false negative (FN) cases (all Ps < .001; Cohen's d = 1.1-1.4), with true positive cases evidencing greater impairment. CONCLUSIONS Community-based primary care clinicians who receive specialty training can make accurate ASD diagnoses in most cases. Diagnostic disagreements were predominately FN cases in which EAE Hub clinicians had difficulty differentiating ASD and global developmental delay. FN cases were associated with a differential diagnostic and phenotypic profile. This research has significant implications for the development of future population health solutions that address ASD diagnostic delays.
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Affiliation(s)
| | - Nancy Swigonski
- Department of Pediatrics, Indiana University School of Medicine
| | - Brett Enneking
- Department of Pediatrics, Indiana University School of Medicine
| | - Tybytha Ryan
- Department of Pediatrics, Indiana University School of Medicine
| | - Patrick Monahan
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine
| | | | - Lisa Hamrick
- Department of Psychological Sciences, Purdue University
| | - Girija Kadlaskar
- Department of Speech, Language & Hearing Sciences, Purdue University
- MIND Institute, University of California Davis
| | - Angela Paxton
- Department of Pediatrics, Indiana University School of Medicine
| | - Mary Ciccarelli
- Department of Pediatrics, Indiana University School of Medicine
| | - Brandon Keehn
- Department of Speech, Language & Hearing Sciences, Purdue University
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de Marchena A, Wieckowski AT, Algur Y, Williams LN, Fernandes S, Thomas RP, McClure LA, Dufek S, Fein D, Stahmer AC, Robins DL. Initial diagnostic impressions of trainees during autism evaluations: High specificity but low sensitivity. Autism Res 2023; 16:1138-1144. [PMID: 37084079 PMCID: PMC10353016 DOI: 10.1002/aur.2933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
Reducing the age of first autism diagnosis facilitates access to critical early intervention services. A current "waitlist crisis" for autism diagnostic evaluation thus demands that we consider novel use of available clinical resources. Previous work has found that expert autism clinicians can identify autism in young children with high specificity after only a brief observation; rapid identification by non-experts remains untested. In the current study, 252 children ages 12-53 months presented for a comprehensive autism diagnostic evaluation. We found that junior clinicians in training to become autism specialists (n = 29) accurately determined whether or not a young child would be diagnosed with autism in the first five minutes of the clinic visit in 75% of cases. Specificity of brief observations was high (0.92), suggesting that brief observations may be an effective tool for triaging young children toward autism-specific interventions. In contrast, the lower negative predictive value (0.71) of brief observations, suggest that they should not be used to rule out autism. When trainees expressed more confidence in their initial impression, their impression was more likely to match the final diagnosis. These findings add to a body of literature showing that clinical observations of suspected autism should be taken seriously, but lack of clinician concern should not be used to rule out autism or overrule other indicators of likely autism, such as parent concern or a positive screening result.
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Affiliation(s)
| | | | - Yasemin Algur
- Department of Epidemiology & Biostatistics, Drexel University, Philadelphia, PA
| | | | | | - Rebecca P. Thomas
- Department of Psychological Sciences, University of Connecticut, Storrs, CT
| | - Leslie A. McClure
- Department of Epidemiology & Biostatistics, Drexel University, Philadelphia, PA
| | - Sarah Dufek
- Department of Psychiatry and Behavioral Sciences, University of California, Davis MIND Institute, Sacramento, CA
| | - Deborah Fein
- Department of Psychological Sciences, University of Connecticut, Storrs, CT
| | - Aubyn C. Stahmer
- Department of Psychiatry and Behavioral Sciences, University of California, Davis MIND Institute, Sacramento, CA
| | - Diana L. Robins
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA
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