Satisfaction with primary health care received by families of children with developmental disabilities

Expectations for Children with Autism Spectrum Disorders or Intellectual Disabilities in Ghana: A Comparison Between Service Providers and Parents

Little is known about care providers' expectations for children with autism spectrum disorders (ASD) and intellectual disabilities (ID) in Ghana. This study used group concept mapping (n = 9) and a quantitative survey (n = 128) to explore and compare service providers' and parents' expectations for children with ASD or ID. Data were analyzed using hierarchical clustering procedures and Multivariate Analysis of Variance (MANOVA). Concept mapping results revealed several expectation clusters, including independence, love and acceptance, equal social rights and opportunities, and professional and caregiver training. MANOVA results revealed significant differences between parents, teachers, and healthcare providers in their perceptions of the importance and likelihood of a child achieving these expectations. Results are discussed in reference to the cultural context, and implications are outlined.

'There was nothing, just absolute darkness': Understanding the needs of those caring for children and young people with complex neurodisability in a diverse UK context: A qualitative exploration in the ENCOMPASS study

BACKGROUND

Children and young people (CYP) with complex neurodisability experience multiple physical, communication, educational and social challenges, which require complex packages of multidisciplinary care. Part of the holistic care required includes supporting the families and parents/caregivers. The aim of the wider study was to introduce a new programme ('Ubuntu') to parents/caregivers and healthcare professionals (HCPs) in order to test the feasibility and acceptability of the concept and content, with the goal of potential adaptation for the UK in mind. Data collection and analysis uncovered rich data on caregiving journeys, navigation of health services, and perceived service gaps. This paper focuses solely on these topics. Further papers will report on the feasibility and adaptation data.

METHODS

Two rounds of semi-structured interviews were conducted with 12 caregivers of CYP with complex neurodisability and six HCPs from a variety of disciplines, recruited from a community child health service in London Borough of Newham, UK in 2020. The interviews included open-ended questions to explore caregiving journeys, experiences of navigating health services and perceived service gaps. Transcripts were analysed using a data-driven inductive thematic analysis.

RESULTS

Three themes were identified that related to the aim of understanding caregivers' experiences and unmet needs relating to current service provision. These were (1) Caregiver Mental Health, (2) The Information Gap and (3) The Need for Holistic Support. Mental health difficulties were reported, particularly around the period of diagnosis. Priority needs included the provision of clear information about the diagnosis and services offered, opportunities to forge peer support networks and for services across the community to collaborate.

CONCLUSIONS

The delivery of health services for CYP with neurodisability should encompass the broad needs of the family as well as meeting the clinical needs of the CYP.

Parent Activation Measure for Developmental Disabilities (PAM-DD) in Caregivers of Individuals With ASD

Activation refers to patients' belief, knowledge, ability, and persistence to manage care. The concept is adapted to parent activation in developmental disorders. This study examined the psychometrics of the Parent Activation Measure for Developmental Disabilities (PAM-DD) and factors related to parent activation in ASD. Data from 658 caregivers of children with ASD in the Autism Treatment Network Registry Call Back Assessment study were analyzed. The actual ordering of the scale items was inconsistent with the assumptions of a Guttman scaling. Factor analysis revealed two PAM-DD factors. Lower child symptom severity was related to higher Factor 1 and lower Factor 2 activation. Future studies should use caution when treating PAM-DD as a Guttman and unidimensional scale.

Caregiver perspectives on barriers and facilitators to primary care for autistic adults: A qualitative study

Background

Primary care is associated with greater access to healthcare services and improved health outcomes. However, autistic adults report challenges accessing and utilizing primary care, in addition to unmet healthcare needs. The need to minimize existing barriers and identify strategies to facilitate successful healthcare encounters is increasingly important as autistic adults represent a growing segment of society. Minimal research has examined primary healthcare encounters for this population.

Methods

As part of a larger convergent parallel design mixed-methods study that recruited autistic adults, caregivers of autistic adults, and primary care providers treating autistic adults, interviews were conducted with 31 caregivers of autistic adults. Caregivers were predominantly female (94%), and the autistic adult they cared for were primarily male (87%), with a mean age of 24 years. Thematic analysis was employed to elucidate the barriers to care, suggestions to mitigate challenges, and/or successful strategies implemented during care encounters for autistic adults, as reported by their caregivers.

Results

Reported here are the results only from the caregiver interviews, in which seven themes emerged: (1) finding a primary care provider; (2) patient-provider communication; (3) anxiety due to unpredictability, an overstimulating sensory environment, and waiting time; (4) participation of consumers in the healthcare process; (5) stigma and assumptions about autism; (6) caregiver experiences; and (7) the impact of culture and ethnicity on care.

Conclusion

Findings from this study have the potential to inform the development of, or improve existing, client-centered interventions to improve primary healthcare services for autistic adults.

Oral Care for Children with Special Healthcare Needs in Dentistry: A Literature Review

Oral health is a very important aspect of general health, especially for vulnerable groups such as children with special healthcare needs. It is important to provide appropriate oral care in order to promote quality of life and good health for everyone, especially for children with special healthcare needs. Method: We reviewed the recent literature to collect knowledge regarding the delivery of quality oral care to children with special healthcare needs. We also explored some of the treatment management options that could address the needs of these children when attending dental clinics. Result: Unfortunately, we noted significant inequalities with issues related to oral health among those children. This situation often results in limitations to the activities of daily living for these children. There is therefore a need for much-needed advancements and refinements in oral healthcare to address the needs of children who have special healthcare needs. Conclusions: Providing children with special healthcare needs with high-quality dental care may necessitate active liaisons with healthcare facilitators and will require work across professions to make certain that these children’s oral health is also prioritized. Coordinated efforts by dental professionals are needed to provide dental health education and preventive interventions for these children.

Developing undergraduate autism education for medical students: a qualitative study

BACKGROUND

Autistic adults and children experience considerable health inequalities and have high rates of premature mortality, hospital admissions and emergency department visits. This is in part due to a lack of autism awareness in the healthcare and social care workforce. A new educational programme, Time for Autism (TfA), for medical students is being developed to address this challenge. This qualitative study was undertaken to support the development of the new programme in order to (1) understand the medical care experiences of parents of autistic children and (2) assess their views on the acceptability of the new TfA programme and willingness to be involved.

METHODS

A convenience sample of 11 parents of autistic children were recruited across the South of England. The ages of the autistic children ranged from 3 to 17 years. Semistructured interviews were completed between October and December 2019. Interview transcripts were analysed using thematic analysis.

RESULTS

Three key themes were identified: diagnosis, experiences of doctors and TfA considerations. There was support for and willingness to take part in a dedicated autism education programme for medical students, and constructive feedback to inform and improve its delivery.

CONCLUSION

The findings from this study provide insights into the medical care experiences of parents/carers of autistic children. Understanding how parents/carers of autistic children would like medical care to be improved can be used to develop TfA and other autism programmes. Parental/carer support for the development of and involvement in an autism medical education programme enhances the feasibility of the new programme.

Unscheduled healthcare for children with intellectual disabilities: A systematic scoping review

Background

The provision of unscheduled healthcare for children with intellectual disability is less researched than that focused on hospital settings or for adult services. The aim of the scoping review was to map the evidence base in this area and identify areas for future study.

Method

A five‐stage scoping review framework was adopted. CINAHL, PubMed, SCOPUS, PsycINFO, Embase, ProQuest Dissertation & Theses and Google Scholar were searched. Studies published in English after 1/1/2000 were considered eligible for inclusion.

Results

A total of 3158 titles and abstracts were screened, 137 full‐text articles were reviewed, and 25 papers met the inclusion criteria. Descriptive themes focused on inequities, needs and experiences of families', poor GP training, and limitations of existing evidence.

Conclusion

Describing trends in healthcare utilisation by this population is valuable for monitoring quality of healthcare, however, addressing observed inequities will require approaches that recognise specific issues within the health system that result in inequities.

Exploring how the diagnostic process stratifies children with intellectual disability navigating the service system in Ontario, Canada

Children with intellectual disability experience a higher prevalence of dental disease, obesity, challenging behaviours, and mental health disorders compared to children without intellectual disability. Children with intellectual disability concurrently face health and social service navigational barriers that are associated with unresolved health needs and hospital admissions, and parent burnout and employment interruptions. In this study, we explored the knowledge gap of how carers and governmental agencies, providing services, understand intellectual disability using discourse analysis, and a theoretical framework applying Deleuze and Guattari's concepts of the rhizome and stratification. We found that children with intellectual disability were stratified into eligible or ineligible service recipients through the diagnostic process that prioritized specified characteristics. Carers did not perceive that their children's unique characteristics and needs were accounted for within the diagnostic process and expressed feelings of being dismissed by clinicians and providers in decision-making about priority needs and services.

Brief Report: Perceptions of Family-Centered Care Across Service Delivery Systems and Types of Caregiver Concerns About Their Toddlers' Development

Family-centered care represents a collaborative partnership between caregivers and service providers, and is associated with positive caregiver and child outcomes. This approach may be especially important for caregivers with early concerns about autism, as service providers are often the gateway to appropriately-specialized intervention. Perceptions of family-centered care received from primary care providers (PCPs) and Part C Early Intervention (EI) providers were rated by two groups of caregivers: those concerned about autism (n = 37) and those concerned about another developmental problem (n = 22), using the Measure of Processes of Care (MPOC-20). Ratings did not differ across caregiver groups, but both groups rated EI providers significantly higher than PCPs, which may reflect systems-level differences between primary care and EI.

Patterns of Nutritional Supplement Use in Children with Tourette Syndrome

Very little is known about the use of nutritional supplements in children with Tourette syndrome. The current study aimed to address the frequency of nutritional supplements and the use of special diets in children with Tourette syndrome and typically developing children. Additional data also sought to address the motivations behind using them, their cost and perceived benefits. A total of 76 responses from an anonymous online survey (Tourette syndrome = 42; typically developing = 34) were completed and analyzed. Fifty-six per cent of children with Tourette syndrome compared to 15% of typically developing children were currently taking nutritional supplements, with the majority take two or more. Thirty-five per cent of the Tourette syndrome compared to 6% typically developing were currently or had previously adopted a special diet. Supplements most used for children with TS included probiotics, omega-3, multivitamins and magnesium. For children with TS, supplementation often began around the age of eight, for a duration on average of 35 months. The average cost was £32.44 a month compared to £8.25 for typically developing children. Seventy-five per cent of supplement users in the Tourette syndrome group noted improvement, mainly in motor and vocal tics, sleep quality and anxiety reduction. Most caregivers learned of supplements through the Internet. In almost 42% of the Tourette syndrome group, their pediatrician was unaware of the supplement use and this rose to 65% for special diets. Given the popularity of nutritional supplements, more research on the effectiveness and safety of such interventions is crucial.

Associations Among Referral Concerns, Screening Results, and Diagnostic Outcomes of Young Children Assessed in a Statewide Early Autism Evaluation Network

OBJECTIVES

To examine associations between referral concerns, screening results, and diagnostic outcomes for young children evaluated across a statewide primary care network for early screening and diagnosis of autism spectrum disorder (ASD).

STUDY DESIGN

The Early Autism Evaluation Hub system was developed to increase developmental screening and improve access to timely ASD evaluations in local communities. In 2019, 858 children (ages 18-48 months; 40% diagnosed with ASD) received ASD evaluations across 12 Early Autism Evaluation Hubs. Data on primary care provider (PCP)- and caregiver-reported referral concerns, Modified Checklist for Autism in Toddlers, Revised with Follow-Up (MCHAT-R/F) and Ages and Stages Questionnaire, Third Edition (ASQ-3), and diagnostic outcome were collected.

RESULTS

Among children evaluated, there was low concordance between PCP and caregiver referral concern. Although a positive MCHAT-R/F screen was associated with PCP but not caregiver-reported ASD referral concern, there was a significant linear relationship between MCHAT-R/F raw scores and both PCP and caregiver ASD referral concern. A different pattern of ASQ-3 delays was found to be associated with PCP-reported as compared with caregiver-reported ASD referral concern. Finally, PCP-reported ASD referral concern, positive MCHAT-R/F, and ASQ-3 Communication and Personal Social delays were associated with a significantly higher likelihood of subsequent ASD diagnosis.

CONCLUSIONS

Understanding how community PCPs use surveillance and screening data, the extent to which PCPs and caregivers have shared understanding and engage in collaborative decision-making about evaluation referral, and how these factors relate to diagnostic outcomes has the potential to impact educational efforts for both PCPs and caregivers of young children, as well as inform the development of more efficacious early identification approaches.

Complementary and Alternative Therapy Use in Children with Cerebral Palsy

OBJECTIVE

To describe complementary and alternative medicine (CAM) use amongst children with cerebral palsy (CP) in Canada and to identify factors associated with CAM use.

METHODS

We conducted a cross-sectional study, utilising data from the Canadian CP Registry. We explored the association between CAM use and regional, socioeconomic and CP phenotypic variables, and parental perception of the family-centredness of clinical care using the Measures of Process of Care-56 (MPOC-56). Chi-square analyses were performed, and odds ratios (OR) and 95% confidence intervals (CI) were obtained. Mann-Whitney U tests were used to compare MPOC-56 scores between CAM users and non-CAM users.

RESULTS

The study sample consisted of 313 families of which 27% reported CAM use in the past year. Children with CP using CAM were more likely to reside in Western Canada (OR 3.3, 95% CI 1.6-6.7), live in a two-parent household (OR 3.5, 95% CI 1.5-8.4), have an ataxic/hypotonic or dyskinetic CP subtype (OR 3.0, 95% CI 1.5-6.1) and have a greater motor impairment (OR 2.8, 95% CI 1.7-4.9). MPOC-56 subscale scores were not significantly associated with CAM use.

CONCLUSION

Physicians need to be aware of existing CAM therapies, the level of evidence supporting their efficacy (beneficence), their associated risks of adverse events (non-maleficence) and enable fair access to care that may be of benefit to each child.

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

Autism as Representative of Disability

Pediatricians care for many children with autism spectrum disorder who demonstrate a wide range of abilities and needs. This population is vulnerable because of lags in diagnosis, difficulty accessing services, overlooked medical conditions, behavioral difficulties during medical visits, parental stress, bullying, comorbid mental health issues, and variable transitional care moving from adolescence to young adulthood. Comprehensive care includes earlier recognition of symptoms with timely referral to early intervention services. It includes primary pediatricians partnering with the family, developmental pediatricians, and other specialists to reduce the vulnerabilities by medical advocacy, family education, and appropriate behavior intervention to improve functioning.

Identification, Evaluation, and Management of Children With Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child's function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions.  This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.

Accessing primary health care services for transition-aged young adults with cerebral palsy; perspectives of young adults, parents, and physicians

Background

Young adults with childhood-onset disabilities experience challenges with accessing age appropriate primary health care services as they transition from pediatric to adult health care services. They often experience a negative impact on their health with associated long-term health and social concerns, disease complications and increased use of emergency services once transitioned to adult services. This is particularly challenging for youth with cerebral palsy (CP) due the complexity of their medical needs. The aim of this study was to explore experiences with accessing or providing primary care services for transitioned-aged young adults with CP from young adult, parent, pediatrician and primary care physician perspectives.

Methods

A qualitative descriptive design was conducted to identify the challenges and facilitators for transitioned aged young adults with accessing primary, adult care services. Semi-structured interviews were conducted with 16 participants within the circle of care (4 adults with CP, 4 parents, 4 pediatricians and 4 primary healthcare physicians) for individuals with CP in Toronto, Canada. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis guided both the data collection and the data analysis processes.

Results

Data analysis revealed that all participant groups reported transition challenges with respect to accessibility, the suitability of some primary care environments for caring for individuals with complex care needs, gaps in seamless care, and limited time and funding when receiving or providing primary care services to young adults with CP.

Discussion

There is a greater demand for adult healthcare providers now to deliver services for adults with childhood onset disabilities. Transition-aged young adults with CP and complex medical needs have increased challenges with accessing primary care services. Considering the following would improve primary care services transition for this population with complex medical needs: ongoing partnering between pediatric and adult health care streams to promote seamless care; connection to team-based primary care services where family physicians, subspecialties and interprofessional practitioners work together to provide joint care planning; salary compensation for increased service needs due to medical complexity; accessible sites; and development of guidelines for transitioning youth/young adults with complex care needs.

Age at referral for diagnosis and rehabilitation services for cerebral palsy: a scoping review

AIM

This study sought to: (1) determine what is known about age at referral for diagnosis and rehabilitation services for children suspected of having cerebral palsy (CP); and (2) identify factors associated with earlier referral.

METHOD

A scoping review was conducted to summarize existing literature. We systematically searched Allied and Complementary Medicine, CINAHL, Cochrane Library, Embase, and PsycINFO for evidence published between 1979 and 2017 on age at referral for diagnosis or age at referral to rehabilitation services for children suspected of having CP. Quantitative and thematic analyses of the literature were performed.

RESULTS

Our search yielded 777 articles, of which 15 met the inclusion criteria. Only one study focused on age at referral for diagnosis of CP (mean 16.6mo±19.2mo), with two on age at referral to rehabilitation services (means 13.9mo±15.8mo and 12.4mo). Potential predictors of earlier referral identified include referral source, type of CP, and a complicated birth history.

INTERPRETATION

Evidence is sparse; however, available studies suggest high variation in the age at which children are being referred for diagnosis, typically ranging from 10 months to 21 months. Evidence indicates that subgroups of children with CP might be experiencing prolonged delays. Findings highlight the need to better understand what contributes to delays in referral for diagnosis and rehabilitation.

WHAT THIS PAPER ADDS

Evidence on age at referral for diagnosis of cerebral palsy is sparse. Potential predictors of delayed referral represent targets to minimize delays in diagnosis. A subset of children may be experiencing unnecessary delays in referral.

The Internet's Effect on Parental Trust in Pediatrician Diagnosis of Autism and Likelihood of Seeking a Second Opinion

This study assessed how web-based information affects parental trust in physician's diagnosis of autism (PDA) and likelihood of seeking a second opinion. Participants of an online survey were randomly allocated to one of three hypothetical scenarios, all were given a vignette of a non-verbal 18-month-old child followed by (1) not viewing Internet results, (2) viewing results suggesting autism, or (3) viewing results suggesting language delay and rated their trust and likelihood of seeking a second opinion. When Internet results contradicted PDA, parents reported less trust in PDA and greater likelihood of seeking a second opinion. Due to the Internet's influence on parents' response to PDA, clinicians should discuss their differential diagnosis with parents, address Internet-related concerns, and recommend trustworthy sources.

Utilization of Complementary and Alternative Therapies in Youth with Developmental Disabilities

Oxidative stress is understood to be involved in the ontology and maintenance of different developmental disabilities. Some complementary and alternative medicine (CAM) therapies have been proposed to modify this relationship by affecting oxidative stress pathways. However, it is unclear which of these CAM therapies are used among children with different developmental disabilities. This study examines the use of these therapies among 10,218 children between the ages of 4 and 17 using the 2012 Child Complementary and Alternative Medicine (CAM) Supplement of the National Health Interview Survey (NHIS) to highlight a potential avenue for intervention and prevention efforts. The results suggest that children with developmental disabilities are more likely to utilize particular CAM therapies that may alter oxidative stress pathways. Future work is needed to assess the potential moderating effect of these CAM therapies and oxidative stress levels among children with different developmental disabilities.

"In Medical School, You Get Far More Training on Medical Stuff than Developmental Stuff": Perspectives on ASD from Ontario Physicians

This study investigated the knowledge and perceived competence of Ontario physicians regarding the diagnosis and treatment of ASDs. Previous research demonstrates that many physicians would like more education regarding diagnosis and treatment of autism spectrum disorders (ASDs). Twenty-seven Ontario physicians filled out a questionnaire and participated in a semi-structured interview. Findings revealed that despite participants' high perceived knowledge regarding diagnosis and treatment of ASDs, they feel uncomfortable in providing care for this population. Furthermore, many participants stated diagnosing and treating ASDs is not within their scope of practice. Findings have implications for increasing physicians' knowledge of diagnosis and treatment of ASDs as well as what is required to enhance healthcare for individuals with ASDs and their families.

Care Quality and Spending Among Commercially Insured Children With Disabilities

OBJECTIVE

To identify opportunities to improve care value for children with disabilities (CWD), we examined CWD prevalence within a commercially insured population and compared outpatient care quality and annual health plan spending levels for CWD relative to children with complex medical conditions without disabilities; children with chronic conditions that are not complex; and children without disabling, complex, or chronic conditions.

METHODS

This cross-sectional study comprised 1,118,081 person-years of Blue Cross Blue Shield Massachusetts data for beneficiaries aged 1 to 19years old during 2008 to 2012. We combined the newly developed and validated Children with Disabilities Algorithm with the Pediatric Medical Complexity Algorithm to identify CWD and non-CWD subgroups. We used 14 validated or National Quality Forum-endorsed measures to assess outpatient care quality and paid claims to examine annual plan spending levels and components.

RESULTS

CWD constituted 4.5% of all enrollees. Care quality for CWD was between 11% and 59% for 8 of 14 quality measures and >80% for the 6 remaining measures and was generally comparable to that for non-CWD subgroups. Annual plan spending among CWD was a median and mean 23% and 53% higher than that for children with complex medical conditions without disabilities, respectively; CWD mean and median values were higher than for all other groups as well.

CONCLUSIONS

CWD were prevalent in our commercially insured population. CWD experienced suboptimal levels of care, but those levels were comparable to non-CWD groups. Improving the care value for CWD involves a deeper understanding of what higher spending delivers and additional aspects of care quality.

Health Care Service Utilization and Cost Among Adults with Autism Spectrum Disorders in a U.S. Integrated Health Care System

Objectives

To compare health care utilization patterns and cost among insured adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls).

Method

We conducted a case-control study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) for at least 9 months each year from 2008 to 2012. Cases (N = 1507) were adults with an ASD diagnosis (ICD-9-CM 299.0-299.8) recorded in the electronic medical record on at least two separate occasions by December 31, 2012. Two control groups, adults with ADHD (N = 9042) defined by ICD-9-CM code 314 and GP (N = 15,070), were randomly selected and frequency matched to cases on gender and age. Health care utilization and cost data were obtained from KPNC databases for the year 2012.

Results

Compared with adults with ADHD, adults with ASD had significantly higher utilization of outpatient visits for primary care (74.2% vs. 66.6%), mental health (43.3% vs. 33.2%), and laboratory services (60.9% vs. 54.4%). Hospitalizations for ambulatory care sensitive diagnoses (5.4% vs. 2.3%) were less frequent overall but more common among adults with ASD than with ADHD. Group differences were larger comparing adults with ASD with GP controls. Gynecology visits and screening for cervical cancer were significantly less common among women with ASD than among women with ADHD (35% vs. 50%) or GP (35% vs. 49%). Total annual mean healthcare costs for adults with ASD were 20% higher than costs for adults with ADHD and double costs for GP.

Conclusion

Adults with ASD had significantly higher rates of utilization across most health care service areas compared with adults with ADHD or GP; however, women with ASD were significantly less likely to have gynecology visits and have screening for cervical cancer.

Lay Summary

We conducted a study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) from 2008 to 2012. We compared how often people attended different types of health care and costs of health care among adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls). The study included 1507 adults with ASD, 9042 with ADHD but not ASD, and 15,070 GP controls with no ASD or ADHD. Health care and cost data were obtained from KPNC databases for the year 2012. The study found that adults with ASD used more outpatient visits for primary care, mental health, and laboratory services than adults with ADHD. Gynecology visits and screening for cervical cancer were less common among women with ASD than among women with ADHD or GP. Health care costs for adults with ASD were higher than costs for adults with ADHD and costs for GP. In conclusion, adults with ASD had higher rates of use of most health care service areas than adults with ADHD or GP; however, women with ASD were less likely to have gynecology visits and have screening for cervical cancer.

Health care for individuals with fragile X Syndrome: Understanding access and quality

BACKGROUND

Previous research suggests that individuals with intellectual or developmental disabilities (IDD) may experience challenges accessing quality health care.

OBJECTIVE/HYPOTHESIS

This study explored parent perceptions of access and quality of health care services for children with fragile X syndrome (FXS), the leading hereditary cause of intellectual/developmental disabilities.

METHODS

Nearly 600 primary caregivers of at least one child with FXS completed an online survey on access, barriers, and quality of health care for their family member with FXS (N = 731).

RESULTS

In a convenience sample of well-educated and affluent caregivers, the majority did not report experiencing difficulties with access to services. Caregivers of younger children and those with lower family incomes reported greater challenges with health care access. Nearly 40% of caregivers indicated that their child's PCP was not as knowledgeable about FXS-related needs as they would prefer, indicating a possible knowledge gap on the part of providers.

CONCLUSIONS

These factors represent potential barriers to quality health care for individuals with FXS, with potential lifelong effects ranging from delayed age of diagnosis to difficulty accessing a PCP in adulthood.

Medical care experiences of children with autism and their parents: A scoping review

Children with autism spectrum disorder (ASD) and their families may benefit from the provision of additional supports in health care settings, particularly when preparing for and attending medical appointments. This review examined literature that describes experiences in medical care settings from the perspective of patients under age 18 with ASD and their caregivers. A scoping review was conducted to examine the experiences of children with ASD and their families in medical care settings. Twenty-nine studies meeting inclusion criteria were identified and reviewed. The review indicated a number of challenges (e.g., parent-reported problems in parent-provider communication and overwhelming environments) as well as factors that facilitate positive experiences (e.g., providing positive reinforcement and explaining exam steps) during medical appointments. Children with ASD and their families are faced with many challenges while receiving care in medical settings. The present review identified many challenges families face, as well as facilitators of positive experiences. Understanding the unique experiences of patients with ASD and their parents will help to improve experiences in medical care settings for children, caregivers, and health care providers.

Disparities in Quality and Access to Care for Children with Developmental Disabilities and Multiple Health Conditions

BACKGROUND

The Maternal Child Health Bureau identified six indicators of quality and accessibility essential in achieving coordinated, family-centered, community-based care for children with special healthcare needs (CSHCN). Previous research examined associations between children with single conditions and individual indicators. We sought to identify disparities in meeting quality and accessibility indicators for children with different condition types.

METHODS

The 2009-2010 National Survey of CSHCN is a nationally representative cross-sectional study with caregiver's reports on 40,242 children (0-17 years). Children were categorized into one of seven conditions groups: physical health (PHC), mental health (MHC), developmental disability (DD), physical and mental (PHC and MHC), physical and developmental (PHC and DD), mental and developmental (MHC and DD) and physical, mental and developmental (PHC, MHC, and DD). Unadjusted and adjusted analyses determined associations between condition group and quality and access indicators.

RESULTS

Children with DD, alone or in combination with another condition, were significantly less likely to meet each indicator (p < 0.01) after adjusting for individual demographic, child's activity limitations and family-related characteristics. Compared with children with PHC, those with all three conditions (PHC, MHC, and DD) had the lowest odds of access to medical home (61 % decreased odds (DO)), community services (67 % DO), and adequate insurance (26 % DO); MHC and DD had the lowest odds of partnering in decision making (51 % DO); DD had the lowest odds of healthcare transition service (66 % DO).

CONCLUSIONS

Children with DD and multiple conditions experience disparities in quality and access to healthcare services, meeting most indictors half as often as other CSHCN.

The medical home for children with autism spectrum disorder: an essential element whose time has come

PURPOSE OF REVIEW

The purpose of this review is to describe the role of the medical home in children with autism spectrum disorder (ASD). A high-quality medical home is essential, given the increase in prevalence of ASD and the array of services, community partners, specialists, therapists, and healthcare team members needed to care for this population.

RECENT FINDINGS

Providing care through the medical home model results in fewer unmet needs. Care coordination and integration are the aspects of the medical home currently most lacking. Navigating the healthcare landscape for children with ASD may be enhanced with patient navigators, integration of physical and behavioral health, and telehealth services.

SUMMARY

Children with ASD have an increased number of medical and mental health needs. Obtaining care via a medical home has been shown to decrease unmet healthcare needs. However, they are less likely to receive care through the medical home model compared with other children with special healthcare needs. Barriers identified by families include a lack of early identification, limited knowledge on educational plans, and unknown community resources. Barriers identified by providers include lack of time, training, and resources. Providing care coordination and family-centered care in a medical home model are essential for children with ASD.

Parents' Experiences and Perceptions when Classifying their Children with Cerebral Palsy: Recommendations for Service Providers

AIMS

This study investigated the experiences and perceptions of parents of children with cerebral palsy (CP) when classifying their children using the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS). The second aim was to collate parents' recommendations for service providers on how to interact and communicate with families.

METHODS

A purposive sample of seven parents participating in the On Track study was recruited. Semi-structured interviews were conducted orally and were audiotaped, transcribed, and coded openly. A descriptive interpretive approach within a pragmatic perspective was used during analysis.

RESULTS

Seven themes encompassing parents' experiences and perspectives reflect a process of increased understanding when classifying their children, with perceptions of utility evident throughout this process. Six recommendations for service providers emerged, including making the child a priority and being a dependable resource.

CONCLUSIONS

Knowledge of parents' experiences when using the GMFCS, MACS, and CFCS can provide useful insight for service providers collaborating with parents to classify function in children with CP. Using the recommendations from these parents can facilitate family-provider collaboration for goal setting and intervention planning.

Addressing medical needs of adolescents and adults with autism spectrum disorders in a primary care setting

Little has been reported about how to improve health care access and delivery for adolescents and adults with autism spectrum disorder. To understand the contributions to the health disparities in the autism spectrum disorder population, we conducted two independent research approaches to learn about current medical needs. A retrospective chart review was performed to evaluate medical comorbidities and medication use. A focus group was also created to address barriers faced in providing medical care. Of 126 charts reviewed, 49% (n = 62) had intellectual disability, 49% (n = 62) had attention-deficit hyperactivity disorder, 52% (n = 65) had anxiety, 41% (n = 52) had obesity, 31% (n = 39) with a history of aggressive behavior, 31% (n = 31) had depression, 22% (n = 28) had seizures, and 9% (n = 11) had hypertension. A Medical Regimen Complexity Index score was determined to examine medication use trends in the autism spectrum disorder population. Medical Regimen Complexity Index scores were significantly higher for patients with intellectual disability, patients with seizures, and patients with a history of aggressive behavior. Both the focus group and our pre-visit assessment identified the waiting room and waiting time as barriers to care. Understanding the comorbidities, polypharmacy, and medical barriers should provide a better understanding of the current health care access and delivery needs of adolescents and adults with autism spectrum disorder.

An online ASD learning module for pediatric health care professionals

Purpose

Youth with autism spectrum disorder (ASD) often have co-occurring health care needs and are likely to come into contact with several health care professionals over their lives. At the hospital, youth with ASD may require specialized supports to optimize health care experiences and for medical services to be delivered safely. At present, there is a limited understanding of how to best support this patient population. The purpose of this paper is to develop, implement, and evaluate an online training module for hospital staff about ASD.

Design/methodology/approach

To evaluate participants’ perceived utility of the learning tool, a post-module survey was administered.

Findings

In all, 102 health care professionals and other hospital staff completed the training and evaluation measure. Majority of participants had prior ASD-focused education (66 percent) and had experience working with at least 20 youths with ASD (57 percent). Majority of participants (88 percent) perceived the information from the module to be helpful in their daily work and reported that they learned something new (63 percent). Participants were interested in receiving additional ASD online module training opportunities on topics including: hands-on behavior management strategies, in-hospital resources, guidance on treatment adherence, and ASD training geared specifically to protection services staff.

Originality/value

The results from this evaluation have important practice implications for hospital staff working with patients with ASD and their families. Evidence-based strategies were easily accessible for staff and the module can be feasibly built upon and expanded as well as disseminated beyond the current hospital setting.

Quality of Primary Care for Children With Disabilities Enrolled in Medicaid

OBJECTIVE

The quality of primary care delivered to Medicaid-insured children with disabilities (CWD) is unknown. We used the newly validated CWD algorithm (CWDA) to examine CWD prevalence among Medicaid enrollees 1 to 18 years old, primary care quality for CWD, and differences in primary care quality for CWD and non-CWD.

METHODS

Cross-sectional study using 2008 Medicaid Analytic eXtract claims data from 9 states, including children with at least 11 months of enrollment (N = 2,671,922 enrollees). We utilized CWDA to identify CWD and applied 12 validated or endorsed pediatric quality measures to assess preventive/screening, acute, and chronic disease care quality. We compared quality for CWD and non-CWD unmatched and matched on age, sex, and number of nondisabling chronic conditions and outpatient encounters.

RESULTS

CWDA identified 5.3% (n = 141,384) of our study population as CWD. Care quality levels for CWD were below 50% on 8 of 12 quality measures (eg, adolescent well visits [44.9%], alcohol/drug treatment engagement [24.9%]). CWD care quality was significantly better than the general population of non-CWD by +0.9% to +15.6% on 9 measures, but significantly worse for 2 measures, chlamydia screening (-3.4%) and no emergency department visits for asthma (-5.0%; all P < .01 to .001). Differences in care quality between CWD and non-CWD were generally smaller or changed direction when CWD were compared to a general population or matched group of non-CWD.

CONCLUSIONS

One in 20 Medicaid-insured children is CWD, and the quality of primary care delivered to CWD is suboptimal. Areas needing improvement include preventive/screening, acute care, and chronic disease management.

Le point de vue de parents d’enfants présentant un trouble du spectre de l’autisme en regard d’un programme public d’intervention comportementale

L’intervention comportementale intensive (ICI) est implantée depuis 2003 dans les services publics québécois destinés aux enfants de 2 à 5 ans ayant un trouble du spectre de l’autisme. Ce choix a été fait sur la base de l’avis d’experts et des données probantes à l’effet que l’ICI représente l’intervention la plus efficace pour les jeunes enfants ayant ce type de trouble. Bien que les effets de l’ICI soient largement documentés, la perception des familles quant aux services d’ICI reçus demeure peu étudiée. À partir d’entretiens effectués auprès de 52 familles, le point de vue des parents concernant les services d’ICI a été abordé selon trois dimensions : l’appréciation générale, les effets perçus sur l’enfant et la famille ainsi que le niveau de satisfaction. Les données ont été recueillies à partir de questions ouvertes, d’un questionnaire structuré et de l’Échelle de satisfaction des services (CSQ-8). Les parents participants rapportent que l’équipe d’intervention, les modalités d’intervention ainsi que le contenu de l’intervention des services ICI sont les principaux points forts des services évalués. Des améliorations pourraient néanmoins être apportées à certaines modalités de dispensation des services, ainsi qu’à l’accessibilité, aux mouvements de personnel et à l’implication des parents. Tous les parents, sauf un, rapportent des effets positifs chez l’enfant, notamment sur les plans de la communication, du fonctionnement cognitif et des aspects sociaux. Les services ont aussi des effets sur le bien-être des parents, leurs habiletés parentales et la vie quotidienne familiale. Plus de 95 % des répondants se sont déclarés satisfaits ou très satisfaits des modalités du programme ICI. Le niveau général de satisfaction est également très élevé.

Comorbidity prevalence, healthcare utilization, and expenditures of Medicaid enrolled adults with autism spectrum disorders

A retrospective data analysis using 2000-2008 three state Medicaid Analytic eXtract was conducted to examine the prevalence and association of comorbidities (psychiatric and non-psychiatric) with healthcare utilization and expenditures of fee-for-service enrolled adults (22-64 years) with and without autism spectrum disorders (International Classification of Diseases, Ninth Revision-clinical modification code: 299.xx). Autism spectrum disorder cases were 1:3 matched to no autism spectrum disorder controls by age, gender, and race using propensity scores. Study outcomes were all-cause healthcare utilization (outpatient office visits, inpatient hospitalizations, emergency room, and prescription drug use) and associated healthcare expenditures. Bivariate analyses (chi-square tests and t-tests), multinomial logistic regressions (healthcare utilization), and generalized linear models with gamma distribution (expenditures) were used. Adults with autism spectrum disorders (n = 1772) had significantly higher rates of psychiatric comorbidity (81%), epilepsy (22%), infections (22%), skin disorders (21%), and hearing impairments (18%). Adults with autism spectrum disorders had higher mean annual outpatient office visits (32_ASD vs 8_noASD) and prescription drug use claims (51_ASD vs 24_noASD) as well as higher mean annual outpatient office visits (US$4375_ASD vs US$824_noASD), emergency room (US$15,929_ASD vs US$2598_noASD), prescription drug use (US$6067_ASD vs US$3144_noASD), and total expenditures (US$13,700_ASD vs US$8560_noASD). The presence of a psychiatric and a non-psychiatric comorbidity among adults with autism spectrum disorders increased the annual total expenditures by US$4952 and US$5084, respectively.

Shared Decision Making and Treatment Decisions for Young Children With Autism Spectrum Disorder

OBJECTIVE

To describe influences on shared decision making between primary care pediatricians and parents of young children with autism spectrum disorder (ASD).

METHODS

We conducted a qualitative study using key informant interviews with 20 pediatricians of varying experience from 10 primary care practices and 20 English-speaking parents of young children (aged 2-5 years) with a parent-reported diagnosis of ASD. Subjects were recruited through purposive sampling. Interviews were audiotaped, transcribed verbatim, and analyzed using an integrated approach to data analysis. Differences in coding were resolved by consensus. We achieved thematic saturation and ceased recruitment after 20 interviews were completed within each group.

RESULTS

Three primary themes emerged: 1) pediatricians and parents reported knowledge gaps by pediatricians about ASD treatments and community resources as well as ambiguity regarding the pediatrician's role in ASD care; 2) there was little communication between parents and pediatricians about treatment choices; 3) use of complementary and alternative medical treatments created conflict between pediatricians and parents, and as a result, parents may independently pursue treatments, without the benefit of discussing safety and efficacy with pediatricians. Despite these barriers, parents desired increased support and guidance from their pediatricians, including for complementary and alternative medicine.

CONCLUSIONS

Much work is needed to effectively foster shared decision making in the context of ASD treatment decisions in primary care, including pediatrician training in ASD to enhance knowledge about evidence-based and novel treatments, clinical practice guidelines, and community resources.

[Level of training in autistic spectrum disorders among hospital paediatricians]

BACKGROUND

Training in autistic spectrum disorders is crucial in order to achieve an early diagnosis. However, the number of papers describing this training is limited. This study describes this level of knowledge among paediatricians from tertiary care hospitals in different regions of Spain and detects areas that need improvement.

MATERIAL AND METHOD

A total of one hundred and fifty-seven (157) paediatricians working in tertiary healthcare hospitals located in three different regions in Spain consented to complete an online questionnaire divided in three sections (socio-demographic, knowledge about childhood autism, and opinion). Data were analysed using SPSS version 15.

RESULTS

The total mean score of participating paediatricians in the questionnaire was 20.34 (± 2.43 SD) out of a total possible score of 23. Approximately two-thirds (65%) of paediatricians scored more or equal to the mean score. The knowledge gap was found to be higher with symptoms of repetitive behaviour patterns, concept of autism, and comorbidity, with no statistical significance. There were no differences in paediatrician scores within different socio-demographic groups. Just under two-thirds (64%) of paediatricians subscribed to the opinion that their own knowledge about autism is limited, and there is a significant lack of knowledge about facilities in every region.

CONCLUSIONS

There is a sufficient level of knowledge about autism among paediatricians in tertiary healthcare, although a lack of awareness about the management of these patients, with poor coordination between the different specialists that are involved in their treatment. Efforts should focus on achieving a better coordination between these specialists, and update the knowledge gaps identified.

An update on the comorbidity of ADHD and ASD: a focus on clinical management

Attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) commonly co-occur. With the DSM-5, clinicians are permitted to make an ASD diagnosis in the context of ADHD. In earlier versions of the DSM, this was not acceptable. Both ASD and ADHD are reported to have had substantial increases in prevalence within the past 10 years. As a function of both the increased prevalence of both disorders as well as the ability to make an ASD diagnosis in ADHD, there has been a significant amount of research focusing on the comorbidity between ADHD and ASD in the past few years. Here, we provide an update on the biological, cognitive and behavioral overlap/distinctiveness between the two neurodevelopmental disorders with a focus on data published in the last four years. Treatment strategies for the comorbid condition as well as future areas of research and clinical need are discussed.

Parent-Reported Shared Decision Making: Autism Spectrum Disorder and Other Neurodevelopmental Disorders

OBJECTIVES

Assess differences in parent-reported shared decision making (SDM) based on diagnostic group in a national sample of children with neurodevelopmental disorders (autism spectrum disorder [ASD], cerebral palsy [CP], or Down syndrome [DS]). Assess contribution of medical home and child functional impairment.

METHODS

Secondary analysis of 2009 to 2010 National Survey of Children with Special Health Care Needs explored reports of 3966 children with ASD, CP, or DS. SDM was defined categorically (SDMcat, present or absent) and continuously (SDMcont, score range 0-12). Regression models were adjusted for child/family characteristics, medical home, functional impairment, and diagnostic group.

RESULTS

SDMcat and SDMcont were significantly lower in the ASD group (56.7% [95% confidence interval = CI, 53.4-59.9] and mean 8.7 [95% CI, 8.5-9.0]), compared with the CP group (70.5% [95% CI, 63.4-76.7] and mean 9.7 [95% CI, 9.3-10.1]), or the DS group (70.8% [95% CI, 61.2-78.8] and mean 10.0 [95% CI, 9.5-10.4]). In adjusted analyses of SDMcat and SDMcont, SDM was more likely among children with a medical home (adjusted odds ratio 6.6, p < .001, mean = 11.9, and p < .001), and less likely for children with greatest functional impairment (adjusted odds ratio 0.4, p = .002, mean = 10.1, and p = .001). Adjusted analysis of SDMcont also showed differences based on diagnostic group with lower SDMcont scores in the ASD group (mean = 10.1 and p = .005) compared with the DS group.

CONCLUSION

A medical home was associated with higher SDM, whereas greater functional impairment and ASD diagnosis were associated with lower SDM.

Use and Perceived Effectiveness of Complementary and Alternative Medicine to Treat and Manage the Symptoms of Autism in Children: A Survey of Parents in a Community Population

OBJECTIVE

Parents of children with autism spectrum disorders (ASDs) often try a variety of treatments for their children, including complementary and alternative medicine (CAM). The objective of this study was to improve understanding of the frequency of CAM use by parents for their children with autism and to quantify the parents' perceived effectiveness of various CAM therapies in mitigating the health and functioning problems associated with autism.

METHODS

Parents in southeastern Virginia were recruited for study participation from local autism organizations and a clinical practice where a large proportion of the patients are children with autism. Parents completed an online survey and answered questions about CAM use for their children with autism, and they rated the perceived effectiveness of each therapy.

RESULTS

Of 194 parents surveyed, 80.9% reported that they had tried some form of CAM for their child with autism. Among CAM users, the most frequently used therapies were multivitamins (58.6%), the gluten-free casein-free diet (54.8%), and methyl B-12 injections (54.1%). The CAM therapies that received the highest average rating of effectiveness were sensory integration therapy, melatonin, and off-label use of prescription antifungal medications.

CONCLUSION

CAM therapies were frequently used in this population, and many were perceived to be effective in helping to ease some of the health challenges associated with autism. CAM therapies for the autism population should be further studied in well-controlled clinical research settings to provide safety and efficacy data on treatments, as well as validated treatment options for those with ASD.

A Framework for Developing a Curriculum Regarding Autism Spectrum Disorders for Primary Care Providers

INTRODUCTION

The prevalence of Autism Spectrum Disorders (ASDs) has increased and varies across age groups. Thus there is an increasing need for educational opportunities for General Practitioners (GPs) and other Primary Care providers to help in early identification and referral to specialist services. An earlier survey of GPs in New South Wales (Australia) demonstrated two broad domains for educational activities: (1) a general knowledge (important for early identification and referral) and (2) surveillance (important for ongoing management).

AIM

To seek further evidence to these domains and synthesize the important contents for educational programs for GPs.

MATERIALS AND METHODS

We conducted a (1) Confirmatory Factor Analysis (CFA) on our original survey data and (2) systematic review of the literature to identify important educational topics, using a life cycle approach.

RESULTS

CFA and literature review support theoretical framework of two domains. Alerts and red flags for ASDs, knowledge of simple surveillance tools, communication of diagnosis with parents, referral pathways particularly to speech pathologists before a formal diagnosis is confirmed, and appreciation of vulnerabilities for identifying supports were important in the general knowledge domain, while supporting the families through transition points such as from pre-school to school entry, secondary school and adolescence, role of psychopharmacology such as medications for sleep issues, and for common co-morbidities of anxiety were important in the surveillance dimension.

CONCLUSION

GP supervisors and medical and nursing educators can use findings from this paper for developing structured learning activities for training primary health care workforce regarding ASD's.

Development of the Children With Disabilities Algorithm

BACKGROUND

A major impediment to understanding quality of care for children with disabilities (CWD) is the lack of a method for identifying this group in claims databases. We developed the CWD algorithm (CWDA), which uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify CWD.

METHODS

We conducted a cross-sectional study that (1) ensured each of the 14,567 codes within the 2012 ICD-9-CM codebook was independently classified by 3 to 9 pediatricians based on the code's likelihood of indicating CWD and (2) triangulated the resulting CWDA against parent and physician assessment of children's disability status by using survey and chart abstraction, respectively. Eight fellowship-trained general pediatricians and 42 subspecialists from across the United States participated in the code classification. Parents of 128 children from a large, free-standing children's hospital participated in the parent survey; charts of 336 children from the same hospital were included in the abstraction study.

RESULTS

CWDA contains 669 ICD-9-CM codes classified as having a ≥75% likelihood of indicating CWD. Examples include 318.2 Profound intellectual disabilities and 780.72 Functional quadriplegia. CWDA sensitivity was 0.75 (95% confidence interval 0.63-0.84) compared with parent report and 0.98 (0.95-0.99) compared with physician assessment; its specificity was 0.86 (0.72-0.95) and 0.50 (0.41-0.59), respectively.

CONCLUSIONS

ICD-9-CM codes can be classified by their likelihood of indicating CWD. CWDA triangulates well with parent report and physician assessment of child disability status. CWDA is a new tool that can be used to assess care quality for CWD.

Brief report: Emergency department utilization by individuals with autism

To identify medical problems most commonly presenting to emergency departments among individuals with autism as compared to non-autistic persons across age groups. Data was obtained from the 2010 National Emergency Department database and was analyzed by age categories: 3-5, 6-11, 12-15, 16-18 and 19 years and older. Epilepsy emerged as the leading presenting diagnosis among those with Autism spectrum disorder (ASD), ages 16-19 years and 19 over. Psychiatric conditions were primary among ASD individuals aged 12-15 years, accounting for more than 11% of all visits. In this sample, age-related differences were noted in medical diagnoses among autistic individuals as compared to non-autistic persons.