Factors related to parental age of first concern in toddlers with autism spectrum disorder

Child Age at Time of First Maternal Concern and Time to Services Among Children with Autism Spectrum Disorder

OBJECTIVE

Early treatment of autism spectrum disorder (ASD) can improve developmental outcomes. Children with ASD from minority families often receive services later. We explored factors related to child's age at time of mother's first concerns about child's development and subsequent time to service initiation among children with ASD.

METHODS

Analysis included 759 preschool-age children classified with ASD based on comprehensive evaluations. Factors associated with retrospectively reported child age at time of first maternal concern and subsequent time to service initiation were investigated using multiple linear regression and Cox proportional hazards.

RESULTS

Earlier maternal concern was associated with multiparity, ≥1 child chronic condition, externalizing behaviors, and younger gestational age, but not race/ethnicity. Time to service initiation was longer for children of non-Latino Black or other than Black or White race and higher developmental level and shorter for children with ≥1 chronic condition and older child age at first maternal concern.

CONCLUSION

Parity, gestational age, and child health and behavior were associated with child age at first maternal concern. Knowledge of child development in multiparous mothers may allow them to recognize potential concerns earlier, suggesting that first time parents may benefit from enhanced education about normal development. Race/ethnicity was not associated with child's age when mothers recognized potential developmental problems; hence, it is unlikely that awareness of ASD symptoms causes racial/ethnic disparities in initiation of services. Delays in time to service initiation among children from racial/ethnic minority groups highlight the need to improve their access to services as soon as developmental concerns are recognized.

Brief Report: Investigating Temporal Factors in the Context of Parenting an Autistic Child

The current study was a secondary analysis of cross-sectional data collected in New Zealand. Parents (n = 291) of an autistic child completed an online survey that included temporal/demographic questions relating to the parent and child, and parent ratings of the child's core ASD symptoms, their parenting stress, and psychological well-being. Child and parent ages were related to ASD core symptoms, parenting stress, and psychological well-being, the parent-child age gap was not. Diagnostic delay was only positively associated with parent depression and negatively associated with child communication impairment. Findings indicated that temporal variables can be predictive of parent well-being and child autism symptoms. The findings suggest that focusing interventions on communication abilities may have positive impacts parental mental health.

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

LAY ABSTRACT

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

Sociocultural factors associated with detection of autism among culturally and linguistically diverse communities in Australia

BACKGROUND

The age at which parents or caregivers first develop concerns about their child's development has significant implications on formal diagnosis and intervention. This study aims to determine the sociocultural factors that are associated with the age and type of first concern reported by parents of autistic children among culturally and linguistically diverse (CALD) communities in Australia. We also assessed whether sociocultural factors predict autism traits measured in terms of social affect (SA), restricted and repetitive behaviours (RRB), and calibrated severity scores (CSS).

METHODS

This study is a secondary data analysis of the data collected from six Autism Specific Early Learning and Care Centres (ASELCCs) as part of the Autism Co-operative Research Centre (CRC) program between 2015 and 2019. Data analysed in this study included a family history questionnaire with sociodemographic and sociocultural information, parent-reported age and type of first concern, and clinician/researcher administered Autism Diagnostic Observation Schedule - Second Edition (ADOS-2) which includes standardised domain-wise scores of social affect (SA) and restricted and repetitive behaviours (RRB) as well as calibrated severity scores (CSS), a measure of severity of autism. Primary analysis included multivariable linear regression models to examine the predictive influence of sociodemographic and sociocultural factors on the dependant variables of age of concern (AOC) and the autism traits (SA, RRB, and CSS).

RESULTS

The mean AOC in the sample was 18.18 months and the most common concerns were speech/language delay, limited social interaction, and hyperactivity/behavioural changes. The multivariable linear regression models showed factors such as increase in age of child, those from a CALD background, annual family income, sibling's autism diagnosis, and developmental concerns to be significantly associated with parental AOC. Additionally, we also found that increase in child's age and CALD status to be significant predictors of autism trait (RRB) and severity measured in terms of the CSS score. Further, females (compared to males) were associated with higher difficulties with social communication and interaction skills.

CONCLUSION

Understanding key factors that contribute to early identification of autism can help tailor awareness programs for parents and caregivers, whilst also informing the development of services focused on serving all CALD communities.

Increased delay from initial concern to diagnosis of autism spectrum disorder and associated health care resource utilization and cost among children aged younger than 6 years in the United States

BACKGROUND: Prolonged delays between first caregiver concern and autism spectrum disorder (ASD) diagnosis have been reported, but associations between length of time to diagnosis (TTD) and health care resource utilization (HCRU) and costs have not been studied in a large sample of children with ASD. OBJECTIVE: To address these informational gaps in the ASD diagnostic pathway. METHODS: This retrospective, observational, single cohort analysis of Optum's administrative claims data from January 1, 2011, to December 31, 2020, included commercially insured children who had 2 or more claims for an ASD diagnosis (earliest diagnosis designated as the index date), were between the ages of older than 1.5 years and 6 years or younger at index date, and were continuously enrolled for up to 48 months before and for 12 months after the index date. Two cohorts (between the ages of older than 1.5 years and 3 years or younger and between the ages of older than 3 years and 6 years or younger at ASD diagnosis) were divided into shorter (less than median) and longer (greater than or equal to median) TTD around each cohort median TTD calculated from the first documented ASD-related concern to the earliest ASD diagnosis, because TTD may vary by age at diagnosis. This exploratory analysis compared all-cause and ASD-related HCRU and costs during a 12-month period preceding ASD diagnosis among children with shorter vs longer TTD. RESULTS: 8,954 children met selection criteria: 4,205 aged 3 years or younger and 4,749 aged older than 3 years at diagnosis, with median TTD of 9.5 and 22.1 months, respectively. In the year preceding ASD diagnosis, children with longer TTD in both age cohorts experienced a greater number of all-cause and ASD-related health care visits compared with those with shorter TTD (mean and median number of office or home visits were approximately 1.5- and 2-fold greater in longer vs shorter TTD groups; P < 0.0001). The mean all-cause medical cost per child in the year preceding ASD diagnosis was approximately 2-fold higher for those with longer vs shorter TTD ($5,268 vs $2,525 in the younger and $5,570 vs $2,265 in the older cohort; P < 0.0001 for both). Mean ASD-related costs were also higher across age cohorts for those with longer vs shorter TTD ($2,355 vs $859 in the younger and $2,351 vs $1,144 in the older cohort; P < 0.0001 for both). CONCLUSIONS: In the year prior to diagnosis, children with longer TTD experienced more frequent health care visits and greater cost burden in their diagnostic journey compared with children with shorter TTD. Novel diagnostic approaches that could accelerate TTD may reduce costs and HCRU for commercially insured children. DISCLOSURES: This study was funded by Cognoa, Inc. Optum received funding from Cognoa to conduct this study. Dr Salomon is an employee and holds stock options of Cognoa, Inc. Dr Campbell was an employee of Cognoa, Inc., at the time this study was conducted. Dr Duhig was an employee of Cognoa, Inc., at the time the study was conducted and holds stock options. Dr Vu, Ms Kruse, Mr Gaur, and Ms Gupta are employees and/or stockholders of Optum. Dr Tibrewal was an employee of Optum at the time the research for this study was conducted. Dr Taraman is an employee and holds stock options of Cognoa, Inc., receives consulting fees from Cognito Therapeutics, volunteers as a board member of the American Academy of Pediatrics California and Orange County Chapter, is a paid advisor for MI10 LLC, and owns stock options of NTX, Inc., and HandzIn.

Parent-reported Early Atypical Development and Age of Diagnosis for Children with Co-occurring Autism and ADHD

Autism and attention-deficit/hyperactivity disorder (ADHD) often co-occur. This survey of 288 New Zealand parents of children diagnosed with autism (n = 111), ADHD (n = 93), or both conditions (n = 84), examined the relations between age of diagnosis and early atypical development, the age specialist consultation was needed and types of specialists seen. Co-occurring autism and ADHD was associated with an earlier ADHD diagnosis and a later autism diagnosis. Parents of children with both diagnoses reported less atypical development in language and social behaviours compared to parents of children of autism, and this co-occurring group also experienced longer wait times to diagnosis, and saw more types of specialists prior to a diagnosis, than those with autism.

Symptoms of Autism Spectrum Disorders Measured by the Qualitative Checklist for Autism in Toddlers in a Large Sample of Polish Toddlers

This study aimed to assess some early symptoms of autism spectrum disorders (ASD) measured by a screening tool developed for an early detection of ASD. We investigated if the early symptoms were associated with toddlers’ age, gender or ASD familial risk status. We used the Polish version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT) to assess 1024 children aged 16 to 36 months. The sample included four groups of participants: typically developing toddlers, toddlers with parent-reported ASD-specific concerns, toddlers at risk for autism due to having an older sibling with ASD, and toddlers with a developmental delay. We found that mean Q-CHAT scores were significantly higher in boys than in girls. We did not find any associations between Q-CHAT scores and age. We observed that toddlers with a familial risk for ASD and those with a developmental delay scored significantly higher than controls. We collated these results with previous studies that used the Q-CHAT and other instruments.

Early Motor Signs in Autism Spectrum Disorder

A growing number of literature data suggest the presence of early impairments in the motor development of children with autism spectrum disorder, which could be often recognized even before the appearance of the classical social communication deficits of autism. In this narrative review, we aimed at performing an update about the available data on the early motor function in children with autism spectrum disorder. Early motor impairment in these children can manifest itself both as a mere delay of motor development and as the presence of atypicalities of motor function, such as a higher rate and a larger inventory, of stereotyped movements both with and without objects. In the perspective of a timely diagnosis, the presence of early motor signs can be an important clue, especially in an individual considered at high risk for autism. Motor and communication (both verbal and non-verbal) skills are connected and a pathogenetic role of early motor dysfunctions in the development of autism can be hypothesized. From this, derives the importance of an early enabling intervention aimed at improving motor skills, which could also have favorable effects on other aspects of development.

The influence of race on parental beliefs and concerns during an autism diagnosis: A mixed-method analysis

LAY ABSTRACT

The goal of this study was to examine if there were differences between races in parental concern and belief about autism spectrum disorder (ASD) and the perspectives of clinicians. We studied 489 children with ASD who were having their first evaluation at an ASD clinic. Parents of White children most often believed that their child had ASD. However, White children whose parents believed the child had ASD were less severe in their symptoms. Parents of Black/African American or Hispanic children were more likely to have concerns about communication than parents of White children. In Hispanic families, parental concern about social communication was related to more severe symptoms in children. We discuss the implications of our findings for diagnosis.

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.

Factors Associated with Restricted, Repetitive Behaviors and Interests and Diagnostic Severity Level Ratings in Young Children with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by restricted, repetitive patterns of behavior and interests (RRBIs). With the latest update to the Diagnostic and Statistical Manual of Mental Disorders, a severity level rating is assigned to the two core features of ASD (American Psychiatric Association in Diagnostic and statistical manual of mental disorders 5 American Psychiatric Association Washington, D.C., 2013). Previous studies have identified factors associated with RRBI severity; however, the relationship among RRBIs, adaptive functioning, and diagnostic severity level remains unclear. The present study investigated whether adaptive functioning and parent-reported ASD symptoms predict RRBI severity in young children with ASD. Additionally, a fine-grained analysis was conducted to examine the factors associated with diagnostic severity level ratings. Several significant associations were found. Study findings and implications for assessment and treatment of RRBIs are discussed.

Utilization of speech-language, occupational and physical therapy by diagnosis of autism spectrum disorder

BACKGROUND

Although Medicaid coverage of treatment for children with autism spectrum disorder (ASD) is expanding, we know little about when children receive speech-language, occupational and/or physical therapy. The objective of this study was to examine the relationships between predisposing, enabling and need characteristics and utilization of speech-language, occupational and physical therapy by diagnosis of ASD.

METHODS

We integrated administrative, Medicaid and Census data using a large sample of children with ASD who enrolled in a 1915(c) Home and Community Based Medicaid waiver in a south-eastern state (N = 1,968) to explore (1) the percent of treatment utilization by ASD diagnosis, (2) the type of therapy utilized and (3) the predisposing, enabling and need characteristics associated with utilization.

RESULTS

The percent of utilization was 71%; 65.8% utilized SLT, 33.4% utilized OT and 18.4% utilized PT. Enabling (i.e., urbanicity, age of diagnosis and early intervention programme enrolment) and need (i.e., intellectual disability) characteristics were associated with utilization whereas predisposing social characteristics (i.e., sex and child race-ethnicity and neighbourhood racial composition, poverty and affluence) were not associated with utilization.

CONCLUSIONS

Findings highlight the value in monitoring when children begin treatment. As governments in the United States and globally work to maximize children's potential, additional research that can inform efforts to facilitate earlier utilization will be key to promoting optimal outcomes.

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

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

Parental First Concerns and Timing of Autism Spectrum Disorder Diagnosis

Specific developmental concerns can distinguish between an early versus later diagnosis of autism spectrum disorder (ASD). Caregiver survey responses of children ≥ 9 years-of-age (2012) with ASD were used to evaluate developmental concerns and associations with age of diagnosis [early (< 3 years: n = 106) vs. later (≥ 3 years: n = 432)] using logistic regression. Concerns arose at mean age 18 and 35-months for children diagnosed early versus later, respectively. Concerns about poor eye contact (aOR 1.81, CI 1.08, 3.05), pointing/gesturing (aOR 2.74, CI 1.60, 4.70), response to own name (aOR 3.03, CI 1.75, 5.23), and babbling/speaking (aOR 1.67, CI 0.98, 2.82) were associated with an early diagnosis. Caregivers and pediatricians are critical in early identification and timely entry into intervention.

Brief Report: Agreement Between Parents and Day-Care Professionals on Early Symptoms Associated with Autism Spectrum Disorders

Early identification of Autism Spectrum Disorders (ASD) has the potential to elicit effective early intervention, improving children's level of functioning and developmental trajectories as well as reducing parental stress. Multiple sources of information, including several informants may facilitate early identification. This study examined the agreement between parents and day-care professionals on how they retrospectively recall early symptoms associated with ASD. In this study, we found fair to excellent agreement on early symptoms between parents and day-care professionals. The finding indicates that day-care centres may be a supplementary area for early identification of ASD. More research is needed to explore day-care centers possible role in this early identification.

Differences in Developmental Concerns of Young Children with Autism Spectrum Disorder Across Racial/Ethnic Groups

PURPOSE

Parents/caregivers of children with autism spectrum disorder (ASD) have varying types of initial concerns regarding their child's development, which may be culturally bound to parents' perceptions of their child's development. This study investigated differences in the types of initial developmental concerns reported by parents or caregivers of different racial/ethnic groups with children in an early intervention program.

METHOD

This study examined the frequency of endorsement of different types of concerns in African American, Caucasian, and Hispanic families.

RESULTS

No significant differences between racial/ethnic groups were found in the endorsement of concerns related to communication, language/speech, motor, problem behavior, sensory, feeding, prematurity, attention, adaptive functioning, and medical conditions. Racial/ethnic groups differed significantly in their endorsement for social concerns.

CONCLUSION

Racial/ethnic group differences were confirmed regarding initial developmental concerns related to social behavior, which may be due to cultural beliefs. The implications of these findings on early identification are discussed.

Screening for Autism Spectrum Disorder: Profiles of Children Who Are Missed

OBJECTIVE

To characterize children presenting with concerns for autism spectrum disorder (ASD) missed by parent-report screeners and to examine benefits of a combined screening approach with the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) and the Ages and Stages Questionnaire, Third Edition (ASQ-3).

METHODS

Participants included were 154 children aged 16 to 42 months presenting for an evaluation at an autism center. Caregivers completed the M-CHAT-R, ASQ-3, and a demographic questionnaire. Children participated in an autism diagnostic evaluation consisting of the Mullen Scales of Early Learning (Mullen) and Autism Diagnostic Observation Schedule, Second Edition (ADOS-2).

RESULTS

A total of 124 children (81%) were diagnosed with ASD. The M-CHAT-R identified 85% (n = 105) of these children. Children with ASD missed by the M-CHAT-R had significantly higher scores on the Mullen and significantly lower scores on the ADOS-2. Of the ASQ-3 domains, the majority (n = 102, 82%) of children with ASD failed the communication domain; missed cases showed similar patterns of higher Mullen scores and lower ADOS-2 scores. When adopting a combined screening approach, using a failed screen from either the M-CHAT-R or ASQ-3 communication domain, 93% of children were identified. Parent-reported concerns on an open-ended questionnaire revealed ASD red flags for many missed cases.

CONCLUSION

Children with ASD missed by screeners had higher scores on developmental testing and lower scores on the ADOS-2; however, children still performed below average on developmental tests. Our findings suggest that a combined screening approach was most effective for identifying children with ASD from a sample group referred for an ASD evaluation.

Automated Extraction of Diagnostic Criteria From Electronic Health Records for Autism Spectrum Disorders: Development, Evaluation, and Application

Background

Electronic health records (EHRs) bring many opportunities for information utilization. One such use is the surveillance conducted by the Centers for Disease Control and Prevention to track cases of autism spectrum disorder (ASD). This process currently comprises manual collection and review of EHRs of 4- and 8-year old children in 11 US states for the presence of ASD criteria. The work is time-consuming and expensive.

Objective

Our objective was to automatically extract from EHRs the description of behaviors noted by the clinicians in evidence of the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Previously, we reported on the classification of entire EHRs as ASD or not. In this work, we focus on the extraction of individual expressions of the different ASD criteria in the text. We intend to facilitate large-scale surveillance efforts for ASD and support analysis of changes over time as well as enable integration with other relevant data.

Methods

We developed a natural language processing (NLP) parser to extract expressions of 12 DSM criteria using 104 patterns and 92 lexicons (1787 terms). The parser is rule-based to enable precise extraction of the entities from the text. The entities themselves are encompassed in the EHRs as very diverse expressions of the diagnostic criteria written by different people at different times (clinicians, speech pathologists, among others). Due to the sparsity of the data, a rule-based approach is best suited until larger datasets can be generated for machine learning algorithms.

Results

We evaluated our rule-based parser and compared it with a machine learning baseline (decision tree). Using a test set of 6636 sentences (50 EHRs), we found that our parser achieved 76% precision, 43% recall (ie, sensitivity), and >99% specificity for criterion extraction. The performance was better for the rule-based approach than for the machine learning baseline (60% precision and 30% recall). For some individual criteria, precision was as high as 97% and recall 57%. Since precision was very high, we were assured that criteria were rarely assigned incorrectly, and our numbers presented a lower bound of their presence in EHRs. We then conducted a case study and parsed 4480 new EHRs covering 10 years of surveillance records from the Arizona Developmental Disabilities Surveillance Program. The social criteria (A1 criteria) showed the biggest change over the years. The communication criteria (A2 criteria) did not distinguish the ASD from the non-ASD records. Among behaviors and interests criteria (A3 criteria), 1 (A3b) was present with much greater frequency in the ASD than in the non-ASD EHRs.

Conclusions

Our results demonstrate that NLP can support large-scale analysis useful for ASD surveillance and research. In the future, we intend to facilitate detailed analysis and integration of national datasets.