Examining Services for Young Children with Autism Spectrum Disorder: Parent Satisfaction and Predictors of Service Utilization

Access to Part C, Early Intervention for children younger than 4 years evaluated for autism spectrum disorder

LAY ABSTRACT

Health disparities are defined as preventable differences in the opportunities to achieve optimal health outcomes experienced by marginalized and underrepresented communities. For families with autistic children, health disparities limit accessing early intervention services-which have been found to improve quality of life and other outcomes. One specific early intervention service in the United States is Individuals with Disabilities Education Act, Part C Early Intervention programs, which are federally funded interventions for children birth-to-three with developmental delays. This study adds to this topic by examining which factors impact accessing Part C, Early Intervention services for children who were evaluated for autism. Results showed that only half of the sample received these services despite there being concerns about development for all children. In addition, results showed that those who identified as Black had decreased odds of having accessed Part C, Early Intervention compared to those who identified as White. These results suggest that there are disparities when it comes to accessing important early intervention services that may be negatively impacting the Black autistic community.

Predicting Intervention Use in Youth with Rare Variants in Autism-Associated Genes

Specialized multidisciplinary supports are important for long-term outcomes for autistic youth. Although family and child factors predict service utilization in autism, little is known with respect to youth with rare, autism-associated genetic variants, who frequently have increased psychiatric, developmental, and behavioral needs. We investigate the impact of family factors on service utilization to determine whether caregiver (autistic features, education, income) and child (autistic features, sex, age, IQ, co-occurring conditions) factors predicted service type (e.g., speech, occupational, behavioral) and intensity (hours/year) among children with autism-associated variants (N = 125), some of whom also had a confirmed ASD diagnosis. Analyses revealed variability in the types of services used across a range of child demographic, behavioral, and mental health characteristics. Speech therapy was the most received service (87.2%). Importantly, behavior therapy was the least received service and post-hoc analyses revealed that use of this therapy was uniquely predicted by ASD diagnosis. However, once children received a particular service, there was largely comparable intensity of services, independent of caregiver and child factors. Findings suggest that demographic and clinical factors impact families' ability to obtain services, with less impact on the intensity of services received. The low receipt of therapies that specifically address core support needs in autism (i.e., behavior therapy) indicates more research is needed on the availability of these services for youth with autism-associated variants, particularly for those who do not meet criteria for an ASD diagnosis but do demonstrate elevated and impactful child autistic features as compared to the general population.

Demographic differences in access to health/therapeutic services over first year of the pandemic: a SPARK COVID-19 impact survey analysis

Introduction

This analysis examined changes in services received and service recovery one-year post-pandemic compared to pre-pandemic levels in children with ASD aged between 19 months and 17 years in various subgroups based on factors such as age, income, race/ethnicity, geographic location, and sex.

Methods

An online, parent report survey was completed by the parents of children with ASD in the SPARK study cohort (N = 6,393). Descriptive statistics, chi-square analyses, and Spearman correlations were performed to study associations between various factors and service access, pre-pandemic and one-year, post-pandemic.

Results

One year after pandemic, the lag in service recovery in children with ASD was greatest for PT/OT services followed by SLT. ABA services only recovered in half of the subgroups. In contrast, SES fully recovered and MH and MED services superseded pre-pandemic levels. Across majority of the timepoints, younger children received more SLT, PT/OT, and ABA services whereas older children received more SES, MH, and MED services. Higher income families accessed more SES, SLT, and ABA whereas lower income families received more MH services. White families received less SLT compared to non-white families. Hispanic families received more SLT services compared to non-Hispanic families. Compared to rural families, urban families received more ABA services at baseline which also recovered one year after the pandemic. Certain counterintuitive findings may be attributed to home/remote schooling leading to reduced access to related services.

Conclusions

Future research and policy changes are needed to address the American healthcare vulnerabilities when serving children with ASD by enhancing the diversity of healthcare formats for continued service access during future pandemics and other similar crises.

Predictors of Access to Early Support in Families of Children with Suspected or Diagnosed Developmental Disabilities in the United Kingdom

This study examined predictors of access to early support amongst families of 0-6-year-old children with suspected or diagnosed developmental disabilities in the United Kingdom. Using survey data from 673 families, multiple regression models were fitted for three outcomes: intervention access, access to early support sources, and unmet need for early support sources. Developmental disability diagnosis and caregiver educational level were associated with intervention access and early support access. Early support access was also associated with child physical health, adaptive skills, caregiver ethnicity, informal support, and statutory statement of special educational needs. Unmet need for early support was associated with economic deprivation, the number of household caregivers, and informal support. Multiple factors influence access to early support. Key implications include enhancing processes for formal identification of need, addressing socioeconomic disparities (e.g., reducing inequalities, increasing funding for services), and providing more accessible services (e.g., coordinating support across services, flexible service provision).

Identifying Needs of Ethiopian and Eritrean American Parents of Autistic Children

Collectively, Ethiopians and Eritreans represent one of the largest African immigrant groups in the US, yet no research to date exists on families from these communities raising autistic children. The purpose of our study was to examine the experiences of Ethiopian and Eritrean families of autistic children including experiences (1) receiving the autism diagnosis and interacting with healthcare providers, (2) obtaining services and supports for children (including satisfaction with services and barriers to care), and (3) accessing services and supports for caregivers and families (including needs and barriers to care). Ethiopian and Eritrean parents (N = 51) raising autistic children in the US completed an online survey. Parents reported limited prior knowledge of autism within their communities and had varied experiences with healthcare providers through the diagnostic process. They endorsed barriers to accessing care for their child and family supports (such as provider shortages and cost of services), service needs, and dissatisfaction with school-based and behavioral supports. Many parents reported a negative impact on workforce participation in order to meet their child's needs. Parents identified needs that would benefit their autistic children and families, such as accessible support groups to obtain relevant information. To our knowledge, this is the first systematic study exploring the experiences of Ethiopian and Eritrean families raising autistic children in the US. We discuss implications of our findings and recommendations for culturally responsive care.

Parent Perceptions of the Effects of Early Intensive Behavioral Interventions for Children with Autism

The current study aimed to understand parents' perceptions of the effects of early intensive behavioral intervention (EIBI) based on the principles of applied behavioral analysis (ABA) and the lasting outcomes for their children with Autism spectrum disorder (ASD). In particular, this study sought to examine parent perceptions of the relationship between the intensity of ABA interventions and current autism symptom severity, adaptive functioning, and school placement. The current study employed a convergent parallel mixed-methods design, which consisted of collecting, analyzing, interpreting, and combining both quantitative and qualitative data. Overall, results suggested that the intensity of previous ABA interventions was a unique predictor of current school placement. Additionally, results suggested that the intensity of previous ABA interventions was a unique predictor of adaptive skills, which was supported by parent interviews. However, the intensity of previous ABA interventions was not a unique predictor of current autism severity. Parent responses to interview questions revealed the imperative nature of the interventions and their effect on service delivery for their children with ASD. Overall, this study provided an increased understanding of parents' perceptions of the effectiveness of EIBI, which in turn may be central to understanding service utilization.

Addressing the Need for Training More School Psychologists to Serve Toddlers and Preschoolers with Autism Spectrum Disorders

The prevalence of autism spectrum disorder (ASD) has risen significantly in the past two decades. Unfortunately, there is a shortage of mental health providers who have specialized training in delivering evidenced-based services to this population. Early intensive behavioral intervention (EIBI) is an evidenced-based treatment recommended for toddlers with ASD, and school psychologists are uniquely positioned to help children with ASD receive it. However, many school psychologists do not receive adequate training in this subspecialty. This paper makes recommendations to school psychology training programs about how to add or improve training in this subspecialty based on the results of an Office of Special Education Programs grant-funded ASD training program which involved collaboration between a NASP-approved and APA-accredited school psychology training program and a community-based early intensive behavioral intervention (EIBI) clinic. The grant supported development of an interdisciplinary didactic and clinical training program to increase the ASD knowledge, skills, and competencies of school psychology graduate students, with the broader goals of developing a replicable training model and increasing the workforce of trained providers for this underserved population. Fifteen graduate students completed the training program. Outcomes related to trainee knowledge, skills, and competencies, trainee satisfaction, and lessons learned over time analyzed within a logic model that guided the project's development and execution can be informative for other school psychology programs undertaking training in this subspecialty.

Predictors of Satisfaction with Autism Treatment Services During COVID-19

The COVID-19 pandemic has created unprecedented challenges and disruptions for autistic individuals receiving specialized treatment services. This caregiver-report survey study (n = 339) explored predictors of satisfaction with autism services during COVID-19 to improve perceived support for these families. Specifically, we investigated whether service delivery medium (telehealth vs. in person), child's emotional functioning, and caregiver stress would predict satisfaction with the most highly utilized services. Satisfaction ratings for ABA/behavioral, speech/language, and occupational therapy were lower when delivered via telehealth as compared to in person. Caregivers who reported higher emotional dysregulation in their children were less satisfied with behavioral therapy services. These results provide a critical caregiver-informed perspective on factors influencing satisfaction with specialized autism services during COVID-19.

Comparing the Impact of Differing Preschool Autism Interventions on Parents in Two Canadian Provinces

Early Intensive Behavioural Intervention (EIBI) is effective for preschoolers with autism spectrum disorder (ASD). Parental measures are rarely included in EIBI effectiveness studies, yet parental distress and lower self-efficacy are associated with poorer child outcomes. Parents of preschoolers with ASD (N = 485) were surveyed at baseline (T1), one-year post-intervention (T2), and school entry (T3) about family distress/crisis, parental self-efficacy, and satisfaction with services in two Canadian provinces. Family distress/crisis decreased and parental self-efficacy increased from T1 to T2. Increases in self-efficacy were largely maintained at T3. Parents were highly satisfied with services. Greater satisfaction for those residing in the province utilizing a parent-coaching model suggests that parent involvement is associated with positive parent outcomes.

Family Empowerment: Predicting Service Utilization for Children with Autism Spectrum Disorder

Families of children with autism spectrum disorder (ASD) often utilize a variety of services. Relatively few studies have examined the relationship between family empowerment and service utilization for this population. The present study investigated the relationship between family empowerment and service utilization in families of children with ASD from the Pacific Northwest. Family empowerment did not predict the use of behavioral services or established related services. However, higher family empowerment was reported for families who reported use of complementary and alternative medicine. Implications for future research and clinical practice are discussed.

Collaboration Between Child Play Therapy and Speech-Language Pathology: Case Reports of a Novel Language and Behavior Intervention

Purpose It has been well documented that a significant number of children with developmental language disorders (DLDs) also exhibit challenging behaviors. In this study, a new intervention (Play and Language [PAL]) was developed through a research collaboration between a speech-language pathologist and a play therapist. The purpose of this clinical focus article is to describe child play therapy techniques and how these, along with early language intervention techniques, may positively impact preschool children's general communication and behavior. Method Students in a communication sciences and disorders program were trained to use a combination of child therapy techniques and language facilitation procedures in the PAL approach. Five preschool children, who displayed DLD and challenging behaviors, participated in a 2-week daily intensive intervention. Pre- and postintervention data for general communication and behavior skills were collected through parent report and language sample data. Student clinician and parent surveys were collected to assess the feasibility of conducting the new intervention and the parent-observed outcomes and satisfaction. Results A majority of the children who participated in the study increased their intelligibility and number of different words. Fewer than half increased their sentence length. These same children decreased their challenging behaviors, with 11 of 14 behaviors being reduced to normal levels. All parents reported satisfaction with their child's results. In addition, students trained to provide the intervention reported high levels of satisfaction with the training to implement PAL and that they were confident in providing the intervention techniques. Conclusion Together, our exploratory data provide preliminary and limited evidence that combining play therapy and language facilitation techniques may improve general communication skills and decrease challenging behaviors within the same intervention. Supplemental Material https://doi.org/10.23641/asha.16840459.

Responsive Parenting as a Target for Telehealth Language Interventions in Fragile X Syndrome: Implications for Scalability and Best Practices

This review highlights the ways in which telehealth procedures can be implemented to help bridge the research-to-practice gap in supporting developmental outcomes for youth with fragile X syndrome (FXS). We review how the literature to date has informed potential treatment targets in the areas of speech and language development with a focus on understanding and supporting the dyadic relationship between the child and their biological mother, who is also impacted biologically. Notably, parental responsivity is an area that is strongly related to child language outcomes, both early and into adolescence, and thus, it is an important treatment target for subsequent interventions. To date, several parent-implemented interventions have been done in FXS across a broad age range (2-17-year-olds) all showing support not only that parents are successful in learning responsive strategies but also that there are subsequent impacts to child language development. Moreover, these interventions were successfully implemented at a distance through telehealth procedures including video teleconferencing and shared recordings of parent-child interactions. This review also addresses potential moderators of treatment gains. Implications for scaling such interventions in the future as well as best practices for incorporating telehealth procedures into future research and intervention programs are also discussed.

Systematic Review of Disparities and Differences in the Access and Use of Allied Health Services Amongst Children with Autism Spectrum Disorders

Individuals with autism spectrum disorder (ASD) often benefit from allied health services such as occupational therapy, speech and language pathology, and applied behavioral analysis. While there is consistent evidence of disparities in access and use of medical services (e.g. dentistry), no such systematic review has examined disparities and differences in allied health use amongst children with ASD. In this systematic review, we examine disparities and differences in service access and use for children with ASD. Our findings suggest that children who are older, have less severe ASD symptoms, are from minority groups, and those from particular geographic regions are less likely to receive allied health services. Limitations and future directions are discussed.

The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

Parents' ratings of post-discharge healthcare for their children born very preterm and their suggestions for improvement: a European cohort study

BACKGROUND

Follow-up of very preterm infants is essential for reducing risks of health and developmental problems and relies on parental engagement. We investigated parents' perceptions of post-discharge healthcare for their children born very preterm in a European multi-country cohort study.

METHODS

Data come from a 5-year follow-up of an area-based cohort of births <32 weeks' gestation in 19 regions from 11 European countries. Perinatal data were collected from medical records and 5-year data from parent-report questionnaires. Parents rated post-discharge care related to their children's preterm birth (poor/fair/good/excellent) and provided free-text suggestions for improvements. We analyzed sociodemographic and medical factors associated with poor/fair ratings, using inverse probability weights to adjust for attrition bias, and assessed free-text responses using thematic analysis.

RESULTS

Questionnaires were returned for 3635 children (53.8% response rate). Care was rated as poor/fair for 14.2% [from 6.1% (France) to 31.6% (Denmark)]; rates were higher when children had health or developmental problems (e.g. cerebral palsy (34.4%) or epilepsy (36.9%)). From 971 responses, 4 themes and 25 subthemes concerning care improvement were identified.

CONCLUSIONS

Parents' experiences provide guidance for improving very preterm children's post-discharge care; this is a priority for children with health and developmental problems as parental dissatisfaction was high.

IMPACT

In a European population-based very preterm birth cohort, parents rated post-discharge healthcare as poor or fair for 14.2% of children, with a wide variation (6.1-31.6%) between countries. Dissatisfaction was reported in over one-third of cases when children had health or developmental difficulties, such as epilepsy or cerebral palsy. Parents' free-text suggestions for improving preterm-related post-discharge healthcare were similar across countries; these focused primarily on better communication with parents and better coordination of care. Parents' lived experiences are a valuable resource for understanding where care improvements are needed and should be included in future research.

Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis

For more than 50 years, "Sensory Integration" has been a theoretical framework for diagnosing and treating disabilities in children under the umbrella of "sensory integration dysfunction" (SID). More recently, the approach has been reframed as "the dimensions of sensory processing" or SPD in place of SID, so the review herein describes this collective framework as sensory integration/sensory processing treatment (SI/SP-T) for ASD. This review is not focused on diagnosis of SI/SPD. Broadly, the SI/SPD intervention approach views a plethora of disabilities such as ADHD, ASD, and disruptive behavior as being exacerbated by difficulties in modulating and integrating sensory input with a primary focus on contributions from tactile, proprioceptive, and vestibular systems which are hypothesized to contribute to core symptoms of the conditions (e.g., ASD). SI/SP intervention procedures include sensory protocols designed to enhance tactile, proprioceptive, and vestibular experiences. SI/SP-T procedures utilize equipment (e.g., lycra swings, balance beams, climbing walls, and trampolines), specific devices (e.g., weighted vests, sensory brushes) and activities (e.g., placing hands in messy substances such as shaving cream, sequenced movements) hypothesized to enhance sensory integration and sensory processing. The approach is reviewed herein to provide a framework for testing SI/SP-T using widely accepted clinical trials and event coding methods used in applied behavior analysis (ABA) and other behavioral interventions. Also, a related but distinct neuroscientific paradigm, multisensory integration, is presented as an independent test of whether SI/SP-T differentially impacts sensory integration and/or multisensory integration. Finally, because SI/SP-T activities include many incidental behavioral events that are known as developmental facilitators (e.g., contingent verbal models/recasts during verbal interactions), there is a compelling need to control for confounds to study the unique impact of sensory-based interventions. Note that SI/SP-T includes very specific and identifiable procedures and materials, so it is reasonable to expect high treatment fidelity when testing the approach. A patient case is presented that illustrates this confound with a known facilitator (recast intervention) and a method for controlling potential confounds in order to conduct unbiased studies of the effects of SI/SP-T approaches that accurately represent SI/SP-T theories of change.

Healthcare access and services use among US children with autism spectrum disorder

This study aimed to determine associations of healthcare access problems with services use among US children with autism spectrum disorder. We analyzed 2011-2014 National Health Interview Survey data on 651 children with autism spectrum disorder aged 2-17 years. There were three measures of healthcare access problems: (1) delays accessing healthcare, (2) difficulty affording healthcare, and (3) trouble finding a primary care provider. There were five service use measures: (1) ⩾4 office visits, (2) ⩾1 well-child visit, (3) flu vaccine, (4) prescription medication, and (5) ⩾1 emergency department visit. Multivariable regression models estimated associations of ⩾1 healthcare access problem with each service use variable and effect modification by socioeconomic status and race and ethnicity. Twenty-nine percent of children with autism spectrum disorder had ⩾1 healthcare access problem. Having ⩾1 healthcare access problem was associated with lower adjusted odds of ⩾1 well-child visit or prescription medication use but higher adjusted odds of ⩾4 office visits or ⩾1 emergency department visit. No significant association was found for flu vaccine. Associations of healthcare access problems with emergency department use were most pronounced for higher socioeconomic status and White, non-Hispanic subgroups. Intervention, such as insurance expansion, is needed to improve healthcare access for children with autism spectrum disorder.