Mothers' Adjustment to Autism: Exploring the Roles of Autism Knowledge and Culture

Urban and rural differences in needs, service use and satisfaction among caregivers of autistic children in Morocco

LAY ABSTRACT

It is very important to understand the needs of caregivers to be able to empower caregivers and to develop or improve services around the world. Therefore, research in different regions is needed to understand differences in caregivers needs between countries, but also between areas within countries. This study investigated differences in needs and service use between caregivers of autistic children in Morocco, living in urban and rural areas. A total of 131 Moroccan caregivers of autistic children took part in the study and responded to an interview survey. The results showed both similarities and differences between urban and rural living caregivers' challenges and needs. Autistic children from urban communities were much more likely to receive intervention and attend school than children from rural communities, even though age and verbal skills of the two groups of children were comparable. Caregivers expressed similar needs for improved care and education, but different challenges in caring. Limited autonomy skills in children were more challenging to rural caregivers, while limited social-communicational skills were more challenging to urban caregivers. These differences may inform healthcare policy-makers and program developers. Adaptive interventions are important to respond to regional needs, resources, and practices. In addition, the results showed the importance of addressing challenges as experienced by caregivers such as costs related to care, barriers in access to information, or stigma. Addressing these issues may help reduce both global and within-country differences in autism care.

Is it me or my child? The association between maternal depression and children's behavior problems in mothers and their children with or without autism

Bidirectional associations between maternal depression and child behavior problems have been reported in prior research, however, few studies examine these relations across varied family contexts. This study examined parenting stress and child diagnosis of autism spectrum disorder (ASD) as moderators of bidirectional associations between maternal depression and child behavior problems over time. Our sample included 86 mother-child dyads who reported maternal depressive symptoms, child behavior problems, and parenting stress at three time points over more than 1 year. Approximately half were mothers of children with ASD (n = 41) and half were mothers of neurotypical children (n = 45). We tested the bidirectional associations between maternal depressive symptoms and children's behavior problems and the potential moderating role of parental stress or child ASD diagnosis on these bidirectional associations using aggregated, lagged, and linear mixed models. Even after controlling for lagged maternal depressive symptoms, child behavior problems were associated with greater subsequent maternal depression at the between-person level, but not at the within-person level. The converse relation of prior maternal depressive symptoms on subsequent child behavior problems was not significant. Neither parenting stress nor child ASD diagnosis moderated bidirectional associations between maternal depressive symptoms and children's behavior problems. Child behavior predicted maternal depression, but the converse was not true, regardless of parenting stress levels or child's ASD diagnosis. For mothers experiencing elevated parenting stress and those with children with ASD, this may help alleviate elevated feelings of guilt related to their children's behavior problems.

Prevalence and Disparities in the Detection of Autism Without Intellectual Disability

BACKGROUND

Intellectual ability predicts functional outcomes for children with autism spectrum disorder (ASD). It is essential to classify ASD children with and without intellectual disability (ID) to aid etiological research, provide services, and inform evidence-based educational and health planning.

METHODS

Using a cross-sectional study design, data from 2000 to 2016 active ASD surveillance among 8-year-olds residing in the New York-New Jersey Metropolitan Area were analyzed to determine ASD prevalence with and without ID. Multivariable Poisson regression models were used to identify trends for ASD with ID (ASD-I) and without ID (ASD-N).

RESULTS

Overall, 4661 8-year-olds were identified with ASD. Those that were ASI-I were 1505 (32.3%) and 2764 (59.3%) were ASD-N. Males were 3794 (81.4%), 946 (20.3%) were non-Hispanic Black (Black), 1230 (26.4%) were Hispanic, and 2114 (45.4%) were non-Hispanic white (white). We observed 2-fold and 5-fold increases in the prevalence of ASD-I and ASD-N, respectively, from 2000-2016. Black children were 30% less likely to be identified with ASD-N compared with white children. Children residing in affluent areas were 80% more likely to be identified with ASD-N compared with children in underserved areas. A greater proportion of children with ASD-I resided in vulnerable areas compared with children with ASD-N. Males had higher prevalence compared with females regardless of ID status; however, male-to-female ratios were slightly lower among ASD-I compared with ASD-N cases.

CONCLUSIONS

One-in-3 children with ASD had ID. Disparities in the identification of ASD without ID were observed among Black and Hispanic children as well as among children residing in underserved areas.

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

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

Lay abstract

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

Latinx caregivers and autism identification: what we know a scoping review

This is a scoping review driven by the broad research question: What are Latinx caregivers' specific facilitators and challenges, if any, in getting a timely diagnosis/identification for their child with autism? Our search resulted in 128 articles across various disciplines. A total of 43 articles were included in the final article set. Employing an inductive process, the experiences of Latinx caregiver(s) in obtaining a diagnosis/identification were coded and categorized. From that process, three broad themes were identified: (1) Diagnosis/identification barriers and facilitators (2) System changes and (3) Cultural adaptations and intersectionality. These themes represent the myriad of considerations that have been purported in the existing body of literature to frame an understanding of the experiences that Latinx/Hispanic caregivers encounter as they seek to obtain an autism diagnosis/identification for their child.

Impact of Antipsychotic Use on Readmission Rates in Children and Adolescents With Autism Spectrum Disorder and Irritability

Background

Risperidone and aripiprazole have been established as standard pharmacological treatments for irritability and associated aggressive behaviors in individuals with autism spectrum disorder (ASD), and are the only drugs approved by the United States Food and Drug Administration for those purposes. However, the rates of readmission with the use of these drugs in the pediatric population have not been studied, leaving a gap in the knowledge of antipsychotic effects. Readmission rates are a valuable metric of treatment efficacy that also reflect the financial burden, morbidity, and medical complications associated with multiple hospitalizations.

Methodology

A retrospective study was conducted in 65 Hospital Corporation of America Healthcare hospitals within the United States from 2016 to 2019. Patients aged 6-17 years with a diagnosis of ASD with irritability were included. The primary outcome was 30-, 60-, and 90-day readmission rates. Chi-square tests of independence and post-hoc analyses were used to assess the relatedness between readmission rate and antipsychotic use, as well as the type of antipsychotic medication if used. A binary regression analysis was used to analyze the relationship between demographic characteristics and readmission rate in this population. Patients on antidepressants, anxiolytics, or medications primarily used as mood stabilizers were excluded from the study to reduce confounding effects of such medications.

Results

A total of 2,375 patients aged 6-17 years were admitted for irritability and a diagnosis of ASD. In total 323 (13.8%) patients were readmitted from this group within 30 days of discharge. After controlling for age, sex, and gender, the use of antipsychotic medication was found to decrease 30- and 90-day readmission rates with an odds ratio of 1.2 to 1.4 times compared to no antipsychotic use (p < 0.04). In patients with autism not on antipsychotics, regression analysis revealed that older age (p = 0.0471) and White race (p = 0.0471) were associated with 30-day readmission (a = 0.05). For these patients, race was also significantly associated with 60-day (p = 0.0494) and 90-day (p = 0.0416) readmission rates. In patients with autism on either risperidone or aripiprazole, age (p = 0.0393) and race (p = 0.0316) were significantly associated with 30-day readmission rate.

Conclusions

Antipsychotic use reduced readmission rates within 30 days and 90 days in patients with irritability and ASD. Additionally, oral aripiprazole and oral risperidone were found to be equally effective in reducing the 30-day readmission rate, and neither was superior in comparison to the other in 30-, 60-, or 90-day readmission rates. The reduced 30- and 90-day readmission rates seen in our study with the use of antipsychotic medications emphasize the importance of antipsychotic use for individuals with ASD and irritability, even if the antipsychotic is not risperidone or aripiprazole. Groups who can particularly benefit from antipsychotic use include individuals who are refractory to first- and second-line therapies, such as behavioral interventions, or for those who present with persistent and serious risk of harm to themselves or others. Additionally, the use of antipsychotic medications in this scenario may reduce hospitalizations within 30 days of discharge, allowing reduction of the financial and emotional strain associated with these readmissions.

Racial, Ethnic, and Sociodemographic Disparities in Diagnosis of Children with Autism Spectrum Disorder

ABSTRACT

This special article uses a biosocial-ecological framework to discuss findings in the literature on racial, ethnic, and sociodemographic diagnostic disparities in autism spectrum disorder. We draw explanations from this framework on the complex and cumulative influences of social injustices across interpersonal and systemic levels.

Cultural Influences on Sibling Relationships, Roles, and Self-Concept in the Context of Autism: Perspectives of Latino/a/x and non-Latino/a/x Siblings

Siblings describe positive and negative aspects of autism and often assume lifelong support roles. Less is known about cultural influences on sibling relationships. This qualitative study characterizes processes linking siblings' autism conceptualizations, sibling relationships, and self-concept using a multicultural framework. Siblings (12 Latino/a/x, 9 non-Latino/a/x white) participated. Data were stratified by ethnicity and analyzed using applied thematic analysis. Latino/a/x and non-Latino/a/x siblings described processes linking autism, relationships, and self-concept differently. Latino/a/x siblings emphasized family roles and identified as caregivers and protectors. Non-Latino/a/x siblings emphasized general sensitivity toward individuals who differed from themselves. Findings may reflect cultural differences in familism, caregiving expectations, and autism conceptualizations, thereby illuminating foundations of siblings' lifelong caregiving roles and highlighting the importance of culturally-sensitive, family-centered care.

The impact of socio-cultural values on autistic women: An interpretative phenomenological analysis

It is well recognised that culture plays an important role in how people experience the world. However, there is limited knowledge on the impact of socio-cultural norms and values on the lives of autistic women. This qualitative study used individual semi-structured interviews to explore how eight cis-gendered autistic women, without co-occurring intellectual disabilities, describe dominant socio-cultural beliefs, values and norms and their influence on their own sense of self. Findings elucidated three interdependent themes related to the ‘pervasive influence of cultural values’, ‘individualisation as an autistic woman’ and ‘social connectivity’. Autistic women described how they experienced their environments and made choices about their place within the dominant culture and the impact of these decisions on their identities and experience. The findings of this study have implications for the continued need to shift societal and clinical attitudes towards understanding and appreciating diversity among autistic women.

Introduction to the Special Issue: Addressing Health Disparities in Pediatric Psychology

This introduction to the special issue on Addressing Health Disparities in Pediatric Psychology provides context for why this special issue is needed, reviews key findings of the accepted articles, and discusses future directions for advancing the field. This special issue, one of three on this topic area that has been put forth in the history of this journal, comes at a critical point in our world. This is a time when the COVID-19 pandemic is systematically infecting Black, Indigenous, and People of Color and when there has been increased attention to systemic racism and intersecting violence inherent in multiple systems, including the justice, health, and educational systems. Using Kilbourne et al. (2016) framework, this special issue focuses on Phase 2 and Phase 3 research. Rather than only identifying health disparities (Phase 1), this issue focuses on understanding mechanisms and translating such understanding into interventions and policy changes. The accepted articles span a wide gamut from obesity to autism to rural populations. Furthermore, the articles provide methods for advancing the field beyond simply noting that systematic differences exist toward strategies to address these inequities. We conclude this introduction by discussing next steps for future research, with hopes that it inspires the next generation to study issues of disparities and inequity in deeper, more meaningful, and impactful ways.