Parents' Experience of the Diagnostic Process for Autistic Spectrum Disorders

Caregiver Perspectives on Telehealth Assessment and Other Supports for Infants with Early Developmental Concerns

This study examined the experiences of families of children with developmental concerns in the first year of life, before formal diagnostic evaluations are typically conducted. We aimed to understand the impact of participation in a telehealth-based research evaluation in infancy, identify existing community-based supports perceived favorably by caregivers, and identify suggestions for future directions. Participants were recruited from an prior study evaluating a telehealth assessment for infants with early social communication delays. Here, we interviewed caregivers (n = 19) who participated in follow-up study in toddlerhood. Transcripts from the semi-structured interviews were transcribed and analyzed using both inductive thematic and content coding approaches. Analysis of these interviews resulted in four core themes describing caregiving during this time: (1) Caregivers felt lonely, overwhelmed, and dismissed by providers, leading to feelings of uncertainty about their child's development and future; (2) Telehealth assessments were appreciated because external supports are minimal, complex to navigate, and do not address all areas of need; (3) Desire for additional community and connection; and (4) Information is power. Caregivers reported participating in the telehealth assessments helped them to feel reassured, validated and supported. Outside the study, they sought a wide variety of services and resources. The most frequent requests were for parent coaching sessions and family navigation. Caregivers experienced uncertainty and disempowerment during the pre-diagnostic period and sought education and guidance during this time. Findings reflect the importance of centering family priorities when developing early intervention services for infants with elevated likelihood of autism.

'We wait and we wait'-caregiver perspectives on autism spectrum disorder services in the Western Cape Province of South Africa

INTRODUCTION

Caregivers of children with autism face significant challenges in navigating health, education and other systems of care to ensure appropriate services for their children. In South Africa, for example, many children with autism are reported to be out of schools and waiting long periods for specialist school placements thus adding to the burden of care for caregivers and raising many questions about equity, diversity and inclusion.

METHODS

Here we performed a qualitative study using focus groups to collect data on the perspectives of caregivers of children with autism waiting for school placement in the Western Cape Province of South Africa. We asked families about their experiences of current autism services and for suggestions to improve service delivery.

RESULTS

The main theme that emerged was 'We wait and we wait'. Caregivers expressed high levels of frustration with existing autism educational and other services. Perspectives about services were captured under three categories. The first category, 'The costs of waiting' describes the socioemotional, financial and time costs associated with having a child with autism wait for educational services. The second category 'Barriers while waiting' describes the attitudinal, structural, process and communication barriers experienced by caregivers while seeking services for their children. The final category 'Expecting action' describes attitudinal, service and policy expectations that caregivers felt could improve service delivery. Caregivers provided 10 recommendations for autism service improvements.

CONCLUSION

Caregivers of children with autism waiting for educational services in the Western Cape Province of South Africa expressed dissatisfaction with existing services. Efforts to find solutions to providing services and support to children with autism waiting for educational services and their caregivers should be prioritized.

Identifying autistic children: Priorities for research arising from a systematic review of parents' experiences of the assessment process

LAY ABSTRACT

Hearing about parents' experiences of having their child recognised as autistic could help improve the supports offered to parents. Our article may also help guide future research on this topic. We made a list of the type of research that interested us. We searched the studies already completed, only studying the research that matched our interests. After reading the studies, we rated their quality using the Critical Appraisal Skills Programme tool.It became clear that parents went through four phases during the identification process. The first phase occurred before their child was identified as autistic. The second involved the actual assessment of their child. Parents' emotional reactions to the news were the focus of the third phase. The final phase occurred after their child was identified as autistic. We discuss the findings of our research. As there are sensitivities involved in conducting research on this topic, we identify how researchers can ensure that their research is of the best quality. We are committed to respecting the human rights of all involved, so we emphasise the need for professionals to develop good relationships with the parents of autistic children. Researchers have recently come to see autism as typical of human diversity. We encourage the professionals involved to adopt this understanding of autistic children and make practical suggestions to enable them to do so.

Community implementation of a brief parent mediated intervention for toddlers with probable or confirmed autism spectrum disorder: feasibility, acceptability, and drivers of success (IE Drmic et al.)

Background

Social ABCs is a caregiver-mediated Naturalistic Developmental Behavioral Intervention for toddlers with confirmed/suspected Autism Spectrum Disorder (ASD), with evidence in controlled research settings. Information is lacking on implementation in community settings. We reported on the treatment effectiveness of this program within a community setting, and the current paper describes the implementation phase of this work. Distinguishing between treatment and implementation effectiveness is critical for transporting interventions from laboratory to community.

Objectives

Describe the implementation of Social ABCs through a large public autism service, supported by a research-community partnership.

Methods

We describe this project through the Exploration, Preparation, Implementation, Sustainment (EPIS) framework as it focuses on implementation of evidence-based practices in publicly funded services. We apply this framework to the reporting stage. This project took place in the context of a 3-year government-funded pilot at a hospital-based publicly funded autism service. Participants: Program developers; Autism Service team; toddlers with suspected/confirmed ASD aged 14-34 months (M = 25.18 months) and their caregivers. Training/supervision: Provided by program developers at tapering intensity. Evaluation: Caregivers completed the Caregiver Diary and satisfaction surveys. We explored training processes, intervention uptake, acceptability, adaptations to fit community context, appropriateness, perceived impact, and facilitators/barriers.

Results

Six coaches were trained to fidelity, and three of these were further trained as Site Trainers. 183 clinically referred families enrolled and 89.4% completed the 12-week program. Caregivers reported increases in adherence and competence, high satisfaction and perceived benefits for their children. Coaches reported high satisfaction. Toddlers were appropriately identified to receive the intervention. Referral processes improved, including decreased referral age, and increased family readiness for diagnostic assessment and subsequent services.

Conclusions

Social ABCs was successfully implemented in a community service through a research-community partnership. The program was feasible, acceptable, and appropriate within a community context. Drivers of success included funding, institutional support, shared decision-making, adaptations to fit context, leadership support, perceived positive impact, and commitment to evaluation.

Navigating their child's attachment-related difficulties: Parents' journey from shame into awareness

Attachment-related difficulties frequently present in child and adolescent clinical services. Yet how parents engage with being informed of their child's attachment-related difficulties is little understood. In this qualitative study, ten parents with a birth child with attachment-related difficulties, as informed by a relevant service, and six healthcare professionals, were interviewed. The aim was to explore both perspectives on how parents experienced and engaged with this process, of their understanding of the child's difficulties and the supports they engaged with. Using grounded theory, the parental journey from shame to awareness is described, based around four main themes: failing as a parent, the process of making sense, a call to action, and awareness of attachment and interrelated difficulties. The intensity of shame and defensive processes felt by parents came through strongly in narratives, forming a key barrier to sense-making and action, while specific clinical, personal and support/resource characteristics facilitated progress. The findings highlight how parents can be better supported into a space of attachment-related awareness and understanding, which may in turn facilitate more positive outcomes for the child. The study also raises wide ranging implications relevant to all involved in the investment, planning and delivery of care for this client group.

The Diagnostic Process for Children with Autism Spectrum Disorder: A Preliminary Study of Jordanian Parents' Perspectives

Although extensive research has been conducted worldwide to investigate the diagnostic process of Autism Spectrum Disorder (ASD), Jordanian parents' experiences have been overlooked. This study explored parents' journeys toward receiving diagnoses for their children with ASD. In particular, it aimed to provide a clear picture of the process for obtaining these diagnoses for children in Jordan.

METHODS

Eighteen semi-structured interviews were carried out with 12 mothers and six fathers of children with ASD aged 5 to 11 years old.

RESULTS

The coding process was based on a thematic analysis method and resulted in the identification of three overlapping themes: dissatisfaction with professionals' abilities to approach parents, an unstructured diagnostic process, and perspectives on diagnosis tools.

CONCLUSIONS

Our data upheld the idea that parental satisfaction with the diagnostic process is influenced by the duration of the process, the information provided, the support offered, and the communication approach used by professionals. Within the local cultural context, parents were significantly impacted by the societal stigma associated with disability when they sought diagnoses for their children with ASD.

Family Impact During the Time Between Autism Screening and Definitive Diagnosis

Over the past 10 years, identification of Autism Spectrum Disorder (ASD) risk has dramatically increased due to the wide-spread implementation of screening programs; yet, there is limited understanding about parent perceptions and experiences during the time period when risk is identified, but prior to receiving a formal diagnosis-a period that can last months to years given the long wait-lists for formal ASD evaluations. The current study aimed to examine parent perceptions of family impact (i.e., the impact their child's behaviors have on the family) between the time of risk-identification and formal diagnosis among 277 children identified as at-risk for ASD through screening positive in primary care. We aimed to compare family impact among those whose child met diagnostic criteria for ASD and those who did not. Parents of children who received a non-ASD diagnosis reported a higher baseline level of family impact (F[1, 274] = 5.82, p = .017); however, perceived difficult child behavior was a stronger predictor of family impact (t[6] = 13.11, p < .001) than later diagnostic group (t[6] = - 2.10, p = .037), and child functioning did not predict family impact (t[6] = -0.31, p = .76). These results suggest that in this population, perceived difficult child behavior is a stronger predictor of family impact than later diagnostic category and should be considered an important factor in family support.

Parent Experiences of Autism Spectrum Disorder Diagnosis: a Scoping Review

The purpose of this review was to identify the quantity, breadth, and methodological characteristics of literature examining parent perspectives of autism spectrum disorder diagnosis, synthesize key research findings, and highlight gaps in the current literature. A systematic search was conducted for the period January 1994–February 2020. One hundred and twenty-two articles underwent data extraction. The majority of studies took place in Europe and North America in high-income countries. Over half of the studies used qualitative methodology. Four key components of the diagnostic experience were identified: journey to assessment, assessment process, delivery of the diagnosis and feedback session, and provision of information, resources, and support. Themes of parental emotions and parental satisfaction with the diagnostic process were also found.

Predicting Parent Reactions at Diagnostic Disclosure Sessions for Autism

Receiving a diagnosis of autism for their child can be a pivotal moment for parents, yet there is little research about how providers can predict parent reactions and adjust their feedback. We investigated factors related to parent reactions during the disclosure session using interviews with providers (n = 6), a parent focus group (n = 10), and a mixed-methods survey of parents (n = 189) of recently diagnosed children. Parents' prior knowledge of autism and anxiety about diagnosis predicted emotional reactions and readiness for next steps. Families anxious about receiving a diagnosis are most in need of information but may leave the session feeling lost and unprepared. Providers can promote positive emotional reactions for parents and prevent confusion by increasing their own positivity, warmth, respect, clarity, and confidence.

Comprehensive Assessment of Individuals With Significant Levels of Intellectual Disability: Challenges, Strategies, and Future Directions

The variety and extent of impairments in individuals with severe-profound levels of intellectual disability (ID) impact their ability to complete valid behavioral assessments. Although standardized assessment is crucial for objectively evaluating patients, many individuals with severe-profound levels of ID perform at the floor of most assessments designed for their chronological age. Additionally, the presence of language and motor impairments may influence the individual's ability to perform a task, even when that task is meant to measure an unrelated construct leading to an underestimation of their true ability. This article provides an overview of the assessment protocols used by multiple groups working with individuals with severe-profound levels of ID, discusses considerations for obtaining high-quality assessment results, and suggests guidelines for standardizing these protocols across the field.

Predictors of Caregivers' Satisfaction with the Management of Children with Autism Spectrum Disorder: A Study at Multiple Levels of Health Care

Background: Caregivers are the initial gatekeepers in the health care management of children with autism spectrum disorder (ASD). Methods: This cross-sectional study aimed to determine the factors associated with caregivers’ satisfaction with different levels of health care services in managing children with ASD in Kelantan. The satisfaction scores of 227 main caregivers of confirmed ASD children were assessed with a modified Parent Satisfaction Scale (PSS) questionnaire. Results: The analysis showed that caregivers who waited longer for a doctor’s consultation in primary care had a reduced PSS score, whereas caregivers who were satisfied with the waiting time in primary care had higher PSS scores. At the secondary care level, caregivers who possessed at least a diploma had reduced PSS scores, whereas caregivers who were satisfied with both doctors’ consultation times and occupational therapy appointments had higher PSS scores. At the tertiary care level, caregivers with an underlying medical problem and who had children undergoing occupational therapy for two months or more had reduced PSS scores. Nevertheless, the analysis showed that caregivers who were concerned with their children’s sleeping problems, who had been informed about parental support, who were satisfied with speech and occupational therapy appointments, who were satisfied with waiting times at tertiary care clinics, and who were satisfied with their doctor’s knowledge and experience had higher PSS scores. Conclusions: This study elucidated the importance of understanding caregivers’ satisfaction in attaining care for their ASD children and highlighted the need to promote factors that would increase caregivers’ satisfaction with current ASD services.

UK parents’ experiences of their child receiving a diagnosis of autism spectrum disorder: A systematic review of the qualitative evidence

The purpose of this article is to systematically identify, appraise and synthesise qualitative research concerning UK parents’ experiences of their child receiving a diagnosis of autism spectrum disorder. In total, 11 articles were located through a systematic search of five databases, reference lists, citations and grey literature. These were critically appraised and their results synthesised using meta-ethnography. The quality scores given to included studies were variable, so suggestions are made to improve reporting of future research. Three third-order constructs were developed: (1) emotional needs, (2) informational needs and (3) relational needs. Each relates to parents’ needs as they navigate the process of making sense of their child by seeking and adjusting to a diagnosis of autism spectrum disorder. Parents’ experiences of assessment and diagnosis of their children varied, but these needs were evident across the course of the process. Fathers seemed to find it more difficult than mothers to reconcile having a child with autism spectrum disorder, which may have been grounded in a sense of exclusion from the assessment process. The findings should be considered by professionals working with children, particularly those directly involved in diagnosing autism spectrum disorder. Clinical implications emphasise the need for consideration of parents’ emotional needs, provision of information to aid understanding, and strong relationships with professionals. Future clinical research, which should be informed by quality standards, might develop and evaluate standards of assessment and diagnosis, including post-diagnostic support.

Parents Suggest Which Indicators of Progress and Outcomes Should be Measured in Young Children with Autism Spectrum Disorder

Evaluation of interventions for children with autism spectrum disorder (ASD) is hampered by the multitude of outcomes measured and tools used. Measurement in research with young children tends to focus on core impairments in ASD. We conducted a systematic review of qualitative studies of what matters to parents. Parent advisory groups completed structured activities to explore their perceptions of the relative importance of a wide range of outcome constructs. Their highest ranked outcomes impacted directly on everyday life and functioning (anxiety, distress, hypersensitivity, sleep problems, happiness, relationships with brothers and sisters, and parent stress). Collaboration between professionals, researchers and parents/carers is required to determine an agreed core set of outcomes to use across evaluation research.

Translation and Validation of the Malay Version of the Parents' Satisfaction Scale (PSS-M) for Assessment of Caregivers' Satisfaction with Health Care Services for Children with Autism Spectrum Disorder

Background: A Malay version of Parent Satisfaction Scale (PSS-M) is needed to investigate the factors contributing to the Malay caregivers’ satisfaction with health care management for children with autism spectrum disorder (ASD). The aim of the study is to translate and validate the questionnaire to assess the caregivers’ satisfaction on health care services. Methods: A cross-sectional study was conducted among 110 caregivers of children with ASD aged between 2 and 17 years old that received treatment at two tertiary care centres in Kelantan. Permission to use the original version of the PSS questionnaire was obtained. The original English version of the PSS was translated into a Malay version following the 10 steps proposed by an established guideline. Pre-testing of the PSS was carried out with 30 caregivers before confirmatory factor analysis (CFA) was established using 110 caregivers. They were asked to assess their understanding of the questionnaire. The one-dimensional questionnaire consists of 11 items, including staff attitudes, availability of staff, supportiveness, and helpfulness. The 5-point Likert scale provided ratings from 1 (strongly disagree) to 5 (strongly agree). Confirmatory factor analysis was performed using a robust maximum likelihood estimator. Results: The analysis showed model fit data with good reliability. Conclusion: The PSS-M shows overall model fitness based on specific indices, with good construct validity and excellent absolute reliability to determine the satisfaction level of caregivers of children with ASD with respect to health care services.

What do nurses think they are doing in pre-school autism assessment?

This study reports on the perspective of all the specialist nurses in community paediatric teams in one NHS trust on their role in pre-school autism assessment. Kim's critical reflective inquiry research method ( Kim, 1999 ) was adapted through the inclusion of the researcher as a participant. Participants reflected on the nursing beliefs and values they hold in common, and on their actions in practice. The study found that the beliefs and values held by these nurses, and their intention to offer holistic nursing delivered through a professional relationship of care, correlated with the kind of care that parents have said families need, and make a unique contribution to team assessment.

Experiences of diagnosing autism spectrum disorder: A survey of professionals in the United Kingdom

To date, research exploring experiences of diagnosing autism spectrum disorder has largely focused on parental perspectives. In order to obtain a more complete account of the autism spectrum disorder diagnostic process, it is essential that the views and experiences of professionals are heard. In this study, 116 multidisciplinary professionals involved in diagnosing autism spectrum disorder in the United Kingdom completed an online questionnaire exploring their experiences and opinions of three key areas of service: accessibility, the diagnostic process and post-diagnostic support. Although professionals were largely satisfied with service accessibility, around 40% of services were failing to provide timely assessments. Standardised diagnostic tools were perceived as helpful and were used consistently, but concerns were raised about their validity in detecting atypical autism spectrum disorder presentations (e.g. females). Several challenges regarding giving autism spectrum disorder diagnoses were reported; these included making sure caregivers understood the diagnosis, pitching information at the correct level and managing distress. Furthermore, the practice of 'upgrading' to a diagnosis of autism spectrum disorder in uncertain or complex cases was reported by many, albeit infrequently, and reasons for this varied widely. Professionals expressed dissatisfaction with post-diagnostic provision, especially onward and long-term support options. They also felt that service improvements were required across populations and across the three key areas of service.

Systematic review of tools to measure outcomes for young children with autism spectrum disorder

BACKGROUND

The needs of children with autism spectrum disorder (ASD) are complex and this is reflected in the number and diversity of outcomes assessed and measurement tools used to collect evidence about children's progress. Relevant outcomes include improvement in core ASD impairments, such as communication, social awareness, sensory sensitivities and repetitiveness; skills such as social functioning and play; participation outcomes such as social inclusion; and parent and family impact.

OBJECTIVES

To examine the measurement properties of tools used to measure progress and outcomes in children with ASD up to the age of 6 years. To identify outcome areas regarded as important by people with ASD and parents.

METHODS

The MeASURe (Measurement in Autism Spectrum disorder Under Review) research collaboration included ASD experts and review methodologists. We undertook systematic review of tools used in ASD early intervention and observational studies from 1992 to 2013; systematic review, using the COSMIN checklist (Consensus-based Standards for the selection of health Measurement Instruments) of papers addressing the measurement properties of identified tools in children with ASD; and synthesis of evidence and gaps. The review design and process was informed throughout by consultation with stakeholders including parents, young people with ASD, clinicians and researchers.

RESULTS

The conceptual framework developed for the review was drawn from the International Classification of Functioning, Disability and Health, including the domains 'Impairments', 'Activity Level Indicators', 'Participation', and 'Family Measures'. In review 1, 10,154 papers were sifted - 3091 by full text - and data extracted from 184; in total, 131 tools were identified, excluding observational coding, study-specific measures and those not in English. In review 2, 2665 papers were sifted and data concerning measurement properties of 57 (43%) tools were extracted from 128 papers. Evidence for the measurement properties of the reviewed tools was combined with information about their accessibility and presentation. Twelve tools were identified as having the strongest supporting evidence, the majority measuring autism characteristics and problem behaviour. The patchy evidence and limited scope of outcomes measured mean these tools do not constitute a 'recommended battery' for use. In particular, there is little evidence that the identified tools would be good at detecting change in intervention studies. The obvious gaps in available outcome measurement include well-being and participation outcomes for children, and family quality-of-life outcomes, domains particularly valued by our informants (young people with ASD and parents).

CONCLUSIONS

This is the first systematic review of the quality and appropriateness of tools designed to monitor progress and outcomes of young children with ASD. Although it was not possible to recommend fully robust tools at this stage, the review consolidates what is known about the field and will act as a benchmark for future developments. With input from parents and other stakeholders, recommendations are made about priority targets for research.

FUTURE WORK

Priorities include development of a tool to measure child quality of life in ASD, and validation of a potential primary outcome tool for trials of early social communication intervention.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002223.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Parents’ views of the National Autistic Society’s EarlyBird Plus Programme

Parent training interventions are recommended for parents soon after their child’s autism spectrum condition diagnosis with the aim of improving parents’ psychological well-being and coping, as well as the child’s behaviour. This report explores parents’ views of the EarlyBird Plus Programme through data collected routinely in the post-programme questionnaire. Participants’ reported increased understanding of autism and improvements in their communication with their child and their ability to manage their child’s behaviour. Parents appeared to value the opportunity to meet with other parents, and the programme seemed acceptable to the majority of parents who attended.

A Stress Model for Couples Parenting Children With Autism Spectrum Disorders and the Introduction of a Mindfulness Intervention

Parents of children with autism spectrum disorders (ASD) are at an increased risk for acute and chronic stress compared to parents of children with other developmental disabilities and parents of children without disabilities. It is plausible that the stressors of having a child with ASD affect the couple relationship; however, few researchers have focused on this dynamic within these families. In this article, we seek to develop a model for how stress operates in families with children with ASD. In developing this new stress model, we describe the characteristics of ASD, discuss stressors that are pronounced in families of children with ASD as supported by the literature, and highlight the limitations of Perry's (2004) model in application to this population. Our expanded stress model includes the addition of parenting couple resources and parenting couple outcomes. Finally, we demonstrate how to apply the model using a mindfulness intervention to promote positive outcomes and strengthen the couple relationship.

Diagnostic evaluation of autism spectrum disorders

Research on the identification and evaluation of autism spectrum disorders is reviewed, and best practices for clinical work are discussed. The latest research on diagnostic tools, and their recommended use, is also reviewed. Recommendations include the use of instruments designed to assess multiple domains of functioning and behavior, the inclusion of parents and caregivers as active partners, and the consideration of developmental factors throughout the diagnostic process.