Disparities in Familiarity With Developmental Disabilities Among Low-Income Parents

Effects of Intersectionality Along the Pathway to Diagnosis for Autistic Children With and Without Co-occurring Attention Deficit Hyperactivity Disorder in a Nationally-Representative Sample

Children with complex behavioral profiles (e.g., ASD + ADHD) may experience delays in obtaining a final diagnosis. Low-resource or underrepresented groups may be at even greater risk for delayed diagnosis. We assessed the effect of sociodemographic factors, symptom complexity and co-occurring conditions, and identifier of first symptoms on diagnostic trajectories among children aged 3-17 years diagnosed with ASD (n = 52) or ASD + ADHD (n = 352) from a nationally-representative sample. Race/ethnicity and gender disparities were evident in both groups. Race, symptom complexity, and co-occuring conditions predicted age of final diagnosis and wait time between first concern and final diagnosis, both of which were staggeringly high. Results suggest a complex influence of sociodemographic factors on the diagnostic pathway, and risk of health disparities as a function of intersectionality.

Sociodemographic Disparities in Attention-Deficit/Hyperactivity Disorder Overdiagnosis and Overtreatment During Elementary School

Attention-deficit/hyperactivity disorder (ADHD) overdiagnosis and overtreatment unnecessarily exposes children to potential harm and contributes to provider and community skepticism toward those with moderate or severe symptoms and significant impairments, resulting in less supportive care. Yet, which sociodemographic groups of children are overdiagnosed and overtreated for ADHD is poorly understood. We conducted descriptive and logistic regression analyses of a population-based subsample of 1,070 U.S. elementary schoolchildren who had displayed above-average levels of independently assessed behavioral, academic, or executive functioning the year prior to their initial ADHD diagnoses and who did not have prior diagnostic histories. Among these children, (a) 27% of White children versus 19% of non-White children were later diagnosed with ADHD and (b) 20% of White children versus 14% of non-White children were later using medication. In adjusted analyses, White children are more likely to later be diagnosed (odds ratio [OR] range = 1.70-2.62) and using medication (OR range = 1.70-2.37) among those whose prior behavioral, academic, and executive functioning suggested that they were unlikely to have ADHD.

Healthcare experiences of patients with Down syndrome from primarily Spanish-speaking households

We report on the health care experiences of individuals with Down syndrome (DS) from families who are primarily Spanish-speaking. Data were collected through three methods: (1) a nationally distributed, 20-item survey, (2) two focus groups with seven family caregivers of individuals with DS who self-identified as living in primarily Spanish speaking households, and (3) 20 interviews with primary care providers (PCPs) who care for patients who are underrepresented minorities. Standard summary statistics were used to analyze the quantitative survey results. Focus group and interview transcripts, as well as an open-ended response question in the survey, were analyzed using qualitative coding methods to identify key themes. Both caregivers and PCPs described how language barriers make giving and receiving quality care difficult. Caregivers additionally described condescending, discriminatory treatment within the medical system and shared feelings of caregiver stress and social isolation. Challenges to care experienced by families of individuals with DS are compounded for Spanish-speaking families, where the ability to build trust with providers and in the health care system may be compromised by cultural and language differences, systemic issues (lack of time or inability to craft more nuanced schedules so that patients with higher needs are offered more time), mistrust, and sometimes, overt racism. Building this trust is critical to improve access to information, care options, and research opportunities, especially for this community that depends on their clinicians and nonprofit groups as trusted messengers. More study is needed to understand how to better reach out to these communities through primary care clinician networks and nonprofit organizations.

Healthcare experiences of patients with Down syndrome who are Black, African American, of African descent, or of mixed race

Scant research has explored the healthcare experiences of people with Down syndrome (DS) in the United States who are Black, African American, of African descent, or of mixed race. The purpose of this study was to identify and describe the barriers and facilitators that such patients and their caregivers face when accessing healthcare. We gathered data in three ways: focus groups with caregivers, a national survey completed by caregivers, and in-depth interviews with primary care providers. Many caregivers and primary care physicians felt that patients with DS who are Black, African American, of African descent, or of mixed race receive a lower quality of medical care than their white counterparts with DS. Caregivers mentioned feeling tired of being reminded by the medical community about their race and wanting acknowledgment that raising a child with DS can be hard at times. Many felt that the medical community's conscious and unconscious racial biases do negatively impact the care of their loved ones with DS. Caregivers desired more race concordant medical providers or, when not possible, medical providers who are willing to learn more about DS and build trusted, longitudinal relationships. Primary care providers discussed the need for funded resources and support services to effectively care for their patients with DS.

An Intervention to Increase Detection of Developmental Delays in Special Supplemental Nutrition Program for Women, Infants, and Children

BACKGROUND

Low-income children are at risk for under-detection of developmental disabilities (DDs). Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics see low-income children regularly in early childhood and could be an important source of referrals to developmental services.

METHODS

This was a site-randomized trial of an intervention to train WIC staff in early identification of DDs, using Center for Disease Control and Prevention's Learn the Signs Act Early (LTSAE) developmental monitoring materials. Seven county WIC agencies in Oregon enrolled: 4 intervention agencies and 3 control agencies. The intervention consisted of an on-site, half-day training regarding signs of developmental delays, use of LTSAE materials, and referral to Early Intervention and Early Childhood Special Education (EI/ECSE). Control sites received no training and continued their usual care and referral processes. Primary study outcome was number of children referred from WIC to EI/ECSE in control versus experimental counties as well as % of referrals evaluated, using data obtained from Oregon's EI/ECSE program. Data for 46 children referred to EI/ECSE were obtained.

RESULTS

Overall, 3 of 4 intervention sites increased their referrals to EI/ECSE, and 0 of 3 control sites increased referrals. Total referrals in the intervention arm increased from 5 to 33 in the intervention arm, but decreased from 6 to 2 in the control arm. In the intervention arm, referrals increased for both boys and girls and for all ages.

CONCLUSIONS

This brief intervention with WIC staff led to short-term increases in EI referrals and evaluations. Such interventions may hold promise for reducing disparities.

A Longitudinal RCT of P-ESDM With and Without Parental Mindfulness Based Stress Reduction: Impact on Child Outcomes

This randomized controlled trial (NCT03889821) examined Mindfulness Based Stress Reduction (MBSR) in conjunction with the Parent-implemented Early Start Denver Model (P-ESDM). A previous report described improved metrics of parental distress (Weitlauf et al. in Pediatrics 145(Supplement 1):S81-S92, 2020). This manuscript examines child outcomes. 63 children with ASD (< 36 months) and their parents received 12 P-ESDM sessions. Half of parents also received MBSR. Longitudinal examination of whole sample means revealed modest improvements in autism severity, cognitive, and adaptive skills. There was not a significant time × group interaction for children whose parents received MBSR. Future work should examine more proximal markers of child or dyadic change to enhance understanding of the impact of providing direct treatment for parents as part of early intervention initiatives.

Research attitudes in families of individuals with Down syndrome: importance for clinical trials

BACKGROUND

Individuals with Down syndrome (DS) are increasingly eligible for clinical trial intervention, particularly for the treatment or prevention of Alzheimer disease (AD). Yet, little is known about research attitudes that may contribute to decisions regarding clinical trial enrollment for people with DS, a gap which is addressed in the current study.

METHODS

The Research Attitudes Questionnaire (RAQ) is a brief validated instrument that measures cultural and social factors which influence clinical trial enrollment decisions in the general population. Applied herein to a cohort of 1002 families who have an individual with DS, this survey was carried out through a national registry (DS-Connect). In addition to the RAQ, demographic data were collected.

RESULTS

The response rate to the survey was 49.9%. Respondents were asked to complete demographic information and to respond to the 7 question RAQ. The scores were stratified by a cut point assigned a priori into those more favorable toward research participation vs. those less favorably inclined. Within this sample, nearly 95% self-identified as the primary caretaker for the individual with DS. The RAQ score analyses generally indicated favorable respondent views toward research with particularly high favorability ratings from respondents who had previously participated in research and from those who were older (P = .01 to .001).

CONCLUSIONS

This is one of the first formal studies to evaluate research attitudes among relatives of individuals with DS and shows the feasibility of using this approach to answer important questions that will guide trialists developing treatments for AD in DS. Future research will require broadening the racial and ethnic mix of respondents and the role that a standardized assessment of research attitudes will have for clinical trial participation.

A systematic review examining caregivers’ of color experiences with the diagnostic process of autism spectrum disorder

There are racial/ethnic disparities in the diagnosis of autism spectrum disorder, including delayed diagnosis, discrimination, and a lack of culturally responsive care. The perspectives of caregivers of color are critical in improving delivery of equitable care. We systematically reviewed articles pertaining to experiences with the diagnostic process among caregivers of color. We entered key terms into five databases to identify literature from 2000 to 2021. Fifteen qualitative studies met inclusion criteria, representing 253 caregivers. We used inductive methods to examine themes across racial and ethnic groups and assessed the quality of included studies. Families of color identified multiple factors that negatively affected the diagnostic process. Systems-level factors included long wait lists and financial concerns. Provider-level factors included minimization of caregiver concerns, a “wait and see” approach, biases, and lack of knowledge. Caregivers also described individual (e.g. knowledge) and family factors (e.g. stigma) that delayed diagnosis and complicated the diagnostic process. Communication barriers were commonly reported, which impeded understanding of autism spectrum disorder. Some families described providers, other individuals, community networks, and self-advocacy as facilitators. Interventions targeting systems- (e.g. Medicaid expansion) and provider-level (e.g. increase training in autism spectrum disorder) factors are needed to increase equity in the autism spectrum disorder diagnostic process.

Lay abstract

Children of color are diagnosed with autism later than White children. Caregivers of color are also more likely than White caregivers to report that their child’s healthcare providers do not treat them as a partner, spend enough time with them, or respect their culture and values. We wanted to better understand the experiences of caregivers of color with the diagnostic process of autism spectrum disorder, from the time they discuss developmental concerns with their child’s primary care provider to when the diagnosis is shared with them. We systematically reviewed the literature and found 15 articles that explored the experiences of caregivers of color. Caregivers of color described that they faced large-scale barriers, such as the cost of appointments, transportation, and long wait lists. They also reported negative experiences with providers, including providers not taking their concerns seriously, making assumptions about caregivers, and delaying referrals for an evaluation. Caregivers stated that their own lack of knowledge of autism spectrum disorder, stigma, their family’s thoughts and opinions, and cultural differences between providers and caregivers served as barriers during the diagnostic process. Communication challenges were discussed and included use of medical and technical jargon, a lack of follow-up, language barriers, and difficulty obtaining high-quality interpreters. Some families described providers, other individuals, community networks, and self-advocacy as helpful during the diagnostic process. Large-scale changes are needed, such as increases in the number of providers who are trained in diagnosing Autism. Provider-level changes (e.g. implicit bias training) are also important for improving caregivers’ experiences.

Understanding the Barriers to Receiving Autism Diagnoses for Hispanic and Latinx Families

Significant disparities exist in early identification of autism spectrum disorder (ASD) for Hispanic and Latinx children. ASD prevalence estimates are approximately identical for White and Black children but lower for Hispanic and Latinx children. Reasons for these racial and ethnic variations are likely multifactorial. This review sought to understand previously described barriers and limitations to accessing ASD diagnostic services in the Latinx and Hispanic communities. Three main categories of existing barriers were identified: (1) parent/family, (2) community, and (3) systemic. These barriers are complex and multifactorial in nature, including circumstantial limitations such as limited English proficiency, noncitizenship, and low-income status. These can limit health care access, and can lead to family and community cultural barriers, poor knowledge about ASD, and social stigma related to disabilities. Understanding and mitigating barriers is essential to reduce disparities to ASD diagnosis in the Hispanic and Latinx community. [Pediatr Ann. 2022;51(4):e167-e171.].

What Happens After a Positive Primary Care Autism Screen Among Historically Underserved Families? Predictors of Evaluation and Autism Diagnosis

OBJECTIVE

Families, pediatric providers, and service systems would benefit from expanded knowledge regarding (1) who is most likely to receive a recommended diagnostic evaluation after a positive primary care-administered autism screen and (2) of those who screen positive, who is most likely to be diagnosed with autism?

METHOD

Participants included 309 predominantly low-income, racial/ethnic minority parents and their child, aged 15 to 27 months, who screened positive on the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). Generalized estimating equations were used to fit models of predictors for each binary outcome: receiving a diagnostic evaluation and receiving an autism diagnosis on evaluation.

RESULTS

Significant predictors of diagnostic evaluation receipt included the parent being older or non-Hispanic and the child having private insurance, lower child communication functioning, or receiving Early Intervention services. Significant predictors of an autism diagnosis on evaluation included male child, lower child communication functioning, screening directly in the parent's preferred language, White/non-Hispanic parent, and no parent history of mood disorder.

CONCLUSION

Children with younger parents, Hispanic ethnicity, relatively higher communication skills, public insurance, and no Early Intervention services were less likely to receive recommended diagnostic care. Reduced likelihood of autism diagnosis after a positive screen in non-White/non-Hispanic subgroups supports previous research indicating issues with M-CHAT-R/F positive predictive power for racial/ethnic minorities. The use of telephonic interpreters to administer screens, as opposed to directly screening in families' preferred languages, may lead to identification of fewer true autism cases. Thus, multilingual clinical staff capacity may improve positive predictive power of autism screening.

Perceived community disability stigma in multicultural, low-income populations: Measure development and validation

BACKGROUND

Stigma and knowledge about disabilities differ across groups, impacting care. No validated measures of perceived community disability stigma exist for families in multicultural communities, at risk for disparities.

AIMS

Develop and validate a brief bilingual (i.e., English/Spanish) perceived disability stigma measure, compare perceived disability and autism stigma, and examine perceived disability stigma by parent sociodemographic characteristics and disability familiarity.

METHODS AND PROCEDURES

Secondary data from 522 parents with children ages 2-5 years were recruited from Oregon WIC Special Supplemental Nutrition Program agencies for a child development and disability survey in 2015. The study sample included items regarding disability familiarity and stigma, among the survey population, which was 50 % Latino. Internal consistency, reliability and structural validity were examined. Secondary data on perceived disability and similar autism stigma items were compared. Nested multivariable linear regression assessed associations of perceived disability stigma with sociodemographic characteristics and disability familiarity.

OUTCOMES AND RESULTS

Five perceived disability stigma items had reasonable internal consistency and performed well in the confirmatory factor analysis. Perceived autism stigma was greater than perceived disability stigma. Latino parents reported less perceived disability stigma than white parents. Parents who knew 1+ individual(s) with a disability reported greater perceived disability stigma.

CONCLUSIONS AND IMPLICATIONS

The perceived disability stigma scale demonstrated sound psychometric properties. Results suggest differences in how stigma is perceived across sociodemographic characteristics and disability familiarity.

Transitioning to Telemedicine During COVID-19: Impact on Perceptions and Use of Telemedicine Procedures for the Diagnosis of Autism in Toddlers

The COVID-19 pandemic has increased the use of telemedicine as an avenue to address the need for diagnostic clarification in young children at risk for autism spectrum disorder (ASD). Although preliminary research has supported the use of telemedicine for identifying ASD in toddlers, little is known about the experiences of practitioners attempting direct-to-home tele-assessment. We surveyed diagnostic providers regarding changes in practice behavior in the initial months of the COVID-19 pandemic and their perceptions of ASD tele-assessment. We also examined the use of the TELE-ASD-PEDS, a novel tool for ASD tele-assessment, in response to COVID-19 at seven sites across the country. Results support the clinical acceptability and diagnostic utility of ASD tele-assessment while also highlighting critical avenues of future investigation.

Comparison of the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) Positive Predictive Value by Race

The Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) is the most widely used screener for ASD. Despite the comparable rate of ASD in Black and White children, the M-CHAT-R/F was validated on a primarily White, Non-Hispanic sample. Few studies have assessed whether the screener performs adequately with racial minorities. This study compared the M-CHAT-R/F Positive Predictive Value (PPV), for ASD, and for any developmental condition, in Black and White children. We also examined M-CHAT-R/F item-level PPV by race. The PPVs for ASD and other developmental disorders were similar in both racial groups for total score and individual items. Therefore, our findings support the use of the M-CHAT-R/F with Black and White children.

Improving autism and developmental screening and referral in US primary care practices serving Latinos

LAY ABSTRACT

Latino children experience delays in access to diagnosis and treatment of autism spectrum disorder. Primary care-based screening of all children for autism spectrum disorder and referring them for services may reduce racial/ethnic differences and improve care. REAL-START, a yearlong screening intervention, was effective in increasing screening for autism spectrum disorder and general developmental delays, increasing therapy referrals, and shortening time for developmental assessment in primary care clinics with Latino patients.

A Conceptual Framework for Understanding the Cultural and Contextual Factors on Autism Across the Globe

Autism research is heavily skewed toward western high-income countries. Culturally appropriate screening and diagnostic instruments for autism are lacking in most low- and middle-income settings where the majority of the global autism population lives. To date, a clear overview of the possible cultural and contextual factors that may affect the process of identifying and diagnosing individuals with autism spectrum disorders (ASD) is missing. This study aims to outline these factors by proposing a conceptual framework. A multidisciplinary review approach was applied to inform the development of the conceptual framework, combining a systematic review of the relevant autism research literature with a wider literature search spanning key texts in global mental health, cultural psychiatry, cross-cultural psychology, and intellectual disability research. The resulting conceptual framework considers the identification, help-seeking, and diagnostic process at four interrelated levels: (a) the expression; (b) recognition; (c) interpretation; and (d) reporting of autism symptoms, and describes the cultural and contextual factors associated with each of these levels, including cultural norms of typical and atypical behavior, culture-specific approaches to parenting, mental health literacy, cultural beliefs, attitudes and stigma, as well as the affordability, availability, accessibility, and acceptability of services. This framework, mapping out the cultural and contextual factors that can affect the identification, help-seeking, and diagnosis of ASD may function as a springboard for the development of culturally appropriate autism screening and diagnostic instruments, and inform future cross-cultural autism research directions. The framework also has relevance for clinicians and policy makers aiming to improve support for underserved autism populations worldwide. Autism Res 2020, 13: 1029-1050. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The vast majority of autism research is conducted in western high-income settings. We therefore know relatively little of how culture and context can affect the identification, help-seeking, and diagnosis of autism across the globe. This study synthesizes what is known from the autism research literature and a broader literature and maps out how culture and context may affect (a) the expression, (b) recognition, (c) interpretation, and (d) reporting of autism symptoms.

Community-Engaged Research to Translate Developmental Screening and Referral Processes into Locally-Relevant, Family-Centered Language

OBJECTIVES

This project employed Boot Camp Translation (BCT) to engage community stakeholders in the translation of developmental screening guidelines and early intervention service recommendations into locally-relevant, family-centered messaging.

METHODS

A subject matter expert provided an overview of development, developmental delay, developmental screening and referral processes, and early intervention to BCT participants. BCT participants and facilitators met in-person and via teleconferencing over the course of 12 months to co-develop locally-relevant messages and materials.

RESULTS

BCT participants focused on defining development, developmental delay, and early intervention, rather than describing developmental screening and referral processes. They proposed several dissemination strategies, and focused much of their effort on the creation of an informational booklet designed to educate and empower caregivers.

CONCLUSIONS FOR PRACTICE

BCT is a useful approach for translating developmental screening guidelines and early intervention recommendations into locally-relevant, family-centered messaging.