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Ferguson EF, Barnett ML, Goodwin JW, Vernon TW. "There is No Help:" Caregiver Perspectives on Service Needs for Adolescents and Adults with Profound Autism. J Autism Dev Disord 2024:10.1007/s10803-024-06451-x. [PMID: 38963473 DOI: 10.1007/s10803-024-06451-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/05/2024]
Abstract
The underrepresentation of individuals with profound autism (who require 24/7 access to care) in autism research has resulted in limited knowledge about their service needs and a lack of evidence-based practices tailored to those needs. This study explored caregiver perspectives on service needs, barriers to accessing care, and treatment priorities to guide treatment development and improvement of service delivery. A sequential mixed-methods design integrated quantitative survey data (n = 423; Mage = 18.89 years; 26.7% female) with qualitative interviews (n = 20) with caregivers of adolescents and adults with profound autism. Quantitative findings indicated regular socialization opportunities were the most frequently endorsed unmet service need (60.3% of caregivers), followed by primary health care with autism-trained staff (59.3%), social skills instruction (55.8%), life skills instruction (51.3%), and behavioral support (47.3%). Higher likelihood of needing social activity groups was associated with elevated emotional reactivity, higher language level, minoritized ethnicity, and lower household income. Greater need for specialized primary health care was associated with lower income, while the need for social and life skills instruction was associated with increased age and elevated dysphoria. Qualitative analysis identified 10 themes that converged and expanded quantitative findings by highlighting a pervasive shortage of individualized, goal-oriented services, common barriers to care, and the priority of developing centralized treatment settings that coordinate care throughout adulthood. This study identified pressing service needs for adolescents and adults with profound autism in the United States. These insights are crucial for improving the accessibility and quality of clinical care.
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Affiliation(s)
- Emily F Ferguson
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, 401 Quarry Rd, Stanford, CA, 94305-5719, USA.
| | | | | | - Ty W Vernon
- University of California, Santa Barbara, CA, USA
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Mazurek MO, Nevill RE, Orlando K, Page K, Howard M, Davis BE. Integration of Family Navigation into ECHO Autism for Pediatric Primary Care in Underserved Communities. J Autism Dev Disord 2024:10.1007/s10803-024-06445-9. [PMID: 38954361 DOI: 10.1007/s10803-024-06445-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/04/2024]
Abstract
Children with autism from underserved communities face complex system-, provider-, and family-level barriers to accessing timely diagnosis and early intervention. The current study evaluated the preliminary effects and feasibility of a new program (ECHO Autism LINKS) that integrated pediatric primary care provider (PCP) training with family navigation (FN) to bridge the gaps between screening, referral, and service access. Three cohorts of PCPs (n = 42) participated in the program, which consisted of 60-minute sessions delivered by Zoom twice per month for 12 months. Each session included didactics, case-based learning, and collaborative discussion with participants and an interdisciplinary team of experts. Family navigators were members of the expert team and provided FN services to families referred by PCP participants. Program attendance and engagement were strong, with 40 cases presented and 258 families referred for FN services, most of whom (83%) needed help accessing and connecting with services, and 13% required ongoing support due to complex needs. PCPs demonstrated significant improvements in self-efficacy in providing best-practice care for children with autism, reported high satisfaction, and observed improved knowledge and practice as a result of the program. The results of this initial pilot provide support for the feasibility, acceptability, and preliminary efficacy of the ECHO Autism LINKS program. The model holds promise in addressing complex barriers to healthcare access by providing both PCPs and families with the knowledge and support they need. Future research is needed to evaluate the efficacy and effectiveness of the program in improving child and family outcomes.
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Affiliation(s)
- Micah O Mazurek
- Department of Human Services, School of Education and Human Development, University of Virginia, 417 Emmet Street South, PO Box 400267, Charlottesville, VA, 22904, USA.
| | - Rose E Nevill
- Department of Human Services, School of Education and Human Development, University of Virginia, 417 Emmet Street South, PO Box 400267, Charlottesville, VA, 22904, USA
| | - Karen Orlando
- Department of Human Services, School of Education and Human Development, University of Virginia, 417 Emmet Street South, PO Box 400267, Charlottesville, VA, 22904, USA
| | - Keith Page
- Department of Human Services, School of Education and Human Development, University of Virginia, 417 Emmet Street South, PO Box 400267, Charlottesville, VA, 22904, USA
| | - Mya Howard
- Department of Human Services, School of Education and Human Development, University of Virginia, 417 Emmet Street South, PO Box 400267, Charlottesville, VA, 22904, USA
| | - Beth Ellen Davis
- Division of Neurodevelopmental and Behavioral Pediatrics, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
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Sohl K, Oberweiser C, Ranum E, Oberweiser C, Cornell W. A Pediatrician's Practical Guide for Navigating Transition to Adulthood with Autistic Youth and Their Caregivers. Pediatr Clin North Am 2024; 71:315-326. [PMID: 38423723 DOI: 10.1016/j.pcl.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
When pediatricians, autistic people, and their families carefully consider and plan for the transition from pediatric care to adult care, there are better outcomes for patients. Pediatricians see their patients over time and are uniquely positioned to help prepare for the changes that come with the transition through adolescents to adulthood. Although programs such as Got Transition offer some guidance on how to navigate the transition from pediatric care to adult care, there is less information on how to help those on the autism spectrum and their families transition to adulthood in other ways.
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Affiliation(s)
- Kristin Sohl
- Department of Pediatrics, University of Missouri School of Medicine, 400 North Keene Street, Columbia, MO 65211, USA; ECHO Autism Communities, University of Missouri School of Medicine, 400 North Keene Street, Columbia, MO 65211, USA.
| | | | - Elly Ranum
- Department of Pediatrics, University of Missouri School of Medicine, 400 North Keene Street, Columbia, MO 65211, USA
| | - Charles Oberweiser
- Schlief School of Accountancy, Stephen F. Austin State University, 1936 North Street, Nacogdoches, TX, USA
| | - Wendy Cornell
- ECHO Autism Communities, University of Missouri School of Medicine, 400 North Keene Street, Columbia, MO 65211, USA; Department of Special Education, College of Education and Human Development, 611 Conley Avenue, Columbia, MO 65211, USA
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Malow BA, Mazurek M, Stobbe G, Agrawal MM, Loftin R, Caudel D, Hess A, Westphal A, Smith J, Shouse J, Cheak-Zamora N, Sohl K. ECHO autism adult healthcare: Training community clinicians to provide quality care for autistic adults. Autism Res 2023; 16:1619-1629. [PMID: 37519223 DOI: 10.1002/aur.2996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023]
Abstract
Autistic adults experience significant unmet healthcare needs, with opportunities for improvement in both the systems and the practitioners who serve this population. Primary care physicians/practitioners (PCPs) are a natural choice to provide comprehensive care to autistic adults but often lack experience in serving this population. This pilot study developed and tested an Extension for Community Healthcare Outcomes (ECHO) Autism model adapted from our previous work, focused specifically on training PCPs in best-practice care for autistic adults. The project was informed directly by the perspectives and preferences of autistic adults, caregivers, and PCPs. Two consecutive cohorts of PCPs participated in ECHO Autism Adult Healthcare sessions. Each cohort met 1 h twice a month for 6 months, with 37 PCPs (n = 20 in Cohort 1, and n = 17 in Cohort 2) participating. Based on findings from the first cohort, adjustments were made to refine the session preparation, curriculum, conduct of the ECHO, resources, and evaluation. After participation in the ECHO Autism program, PCP self-efficacy and satisfaction improved, while the number of perceived barriers did not change. Knowledge did not improve significantly in Cohort 1, but after adjustments to the training model, participants in Cohort 2 showed significant knowledge gains. While attention to systems of care is critical to addressing barriers in healthcare in the autistic population, the ECHO Autism Adult Healthcare model is feasible and holds promise for improving PCP satisfaction and self-efficacy in working with autistic adults.
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Affiliation(s)
- Beth A Malow
- Sleep Disorders Division, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Kennedy Center for Excellence in Developmental Disabilities, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Micah Mazurek
- Department of Human Services, University of Virginia, Charlottesville, Virginia, USA
| | - Gary Stobbe
- Center on Human Development and Disability, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Mavara M Agrawal
- Department of Humanities, Health and Society, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Rachel Loftin
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| | - David Caudel
- Frist Center for Autism and Innovation, Department of Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Amy Hess
- Behavioral Health, Child Development Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Alexander Westphal
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joshua Smith
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janet Shouse
- Vanderbilt Kennedy Center for Excellence in Developmental Disabilities, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy Cheak-Zamora
- Department of Health Sciences, University of Missouri, Columbia, Missouri, USA
| | - Kristin Sohl
- Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri, USA
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Sohl K, Levinstein L, James A, Greer S, Boles K, Curran AB, Mahurin M, Mazurek MO, Nanclares V. ECHO (Extension for Community Healthcare Outcomes) Autism STAT: A Diagnostic Accuracy Study of Community-Based Primary Care Diagnosis of Autism Spectrum Disorder. J Dev Behav Pediatr 2023; 44:e177-e184. [PMID: 36978232 DOI: 10.1097/dbp.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
OBJECTIVE Children can be reliably diagnosed with autism spectrum disorder (ASD) by a highly trained clinician as early as 12 to 24 months of age, but recent estimates indicate that the average age of diagnosis is 4.4 years. We hypothesized that trained primary care physicians and practitioners can reliably and accurately diagnose children 14 to 48 months with unambiguous symptoms of ASD. METHODS Through this diagnostic accuracy study, 20 patients diagnosed with ASD by clinicians trained through the ECHO (Extension for Community Healthcare Outcomes) Autism STAT program participated in an independent gold-standard evaluation at a regional autism center. Caregiver perceptions of the diagnostic process were also assessed. RESULTS Of the 20 patients who received a diagnosis of ASD by a trained clinician and completed the study, 19 diagnoses were confirmed by a gold-standard evaluation. Caregivers indicated that undergoing diagnosis in their local community rather than an autism specialty center was helpful (4.8/5 on a 5-point Likert scale, n = 19). Results of this study demonstrate that primary care clinicians can be trained to reliably diagnose ASD in children 14 to 48 months with unambiguous symptoms. CONCLUSION Diagnosis in the primary care setting may lead to earlier diagnosis and quicker connection to evidence-based therapies and interventions. Given the potential impact of increasing access to high-quality diagnostic services, the role of primary care clinicians in the diagnosis of ASD should be further evaluated.
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Affiliation(s)
- Kristin Sohl
- University of Missouri, School of Medicine, Columbia, MO
- Department of Child Health, University of Missouri, Columbia, MO
| | | | - Alexandra James
- University of Missouri, School of Medicine, Columbia, MO
- Department of Child Health, University of Missouri, Columbia, MO
| | - Sophia Greer
- University of Missouri, School of Medicine, Columbia, MO
| | - Katrina Boles
- Department of Child Health, University of Missouri, Columbia, MO
| | | | - Melissa Mahurin
- Department of Child Health, University of Missouri, Columbia, MO
| | - Micah O Mazurek
- University of Virginia, School of Education and Human Development, Charlottesville, VA
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Bloor D, Ballantyne C, Gillespie-Smith K, Wilson C, Hendry G. Investigating the challenges of teaching sex education to autistic learners: A qualitative exploration of teachers' experiences. RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 131:104344. [PMID: 36182810 DOI: 10.1016/j.ridd.2022.104344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Sex education is essential as it equips individuals with the knowledge to live independent and safe sex lives. However, in the United Kingdom, sex education is not particularly accessible for autistic learners which may lead to a lack of knowledge around appropriate sexual behaviours. AIMS The current study focusses on the challenges of teaching sex education to autistic learners. METHODS AND PROCEDURES The data was produced through one-to-one interviews with thirteen educational practitioners that have experienced delivering sex education to autistic learners. OUTCOMES AND RESULTS Reflexive thematic analysis (Braun & Clarke, 2006) was used to interpret the data, producing themes of (1) Pedagogical Restrictions, and (2) Sexual Impulses. CONCLUSIONS AND IMPLICATIONS These findings demonstrated that the main challenges of teaching sex education to autistic learners pertained to Pedagogical Restrictions in the classroom, and learners' own sexual impulses. These findings are a positive step towards understanding how to adapt sex education lessons to make them more inclusive and accessible for learners with autism. This study contributes to developing understanding around how to support autistic learners, highlighting gaps in the current sex education curriculum for policy makers, and enabling those surrounding autistic individuals to best support them with body transformations.
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Affiliation(s)
- Daisy Bloor
- School of Education, University of Glasgow, UK
| | - Carrie Ballantyne
- School of Education and Social Sciences, University of the West of Scotland, UK
| | | | | | - Gillian Hendry
- School of Education and Social Sciences, University of the West of Scotland, UK.
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Physician Voices on ECHO Autism India-Evaluation of a Telementoring Model for Autism in a Low-Middle Income Country. J Dev Behav Pediatr 2022; 43:335-345. [PMID: 35013067 DOI: 10.1097/dbp.0000000000001060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 12/30/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Training pediatricians in low- and middle-income countries (LMICs) in early diagnosis and comprehensive management of autism spectrum disorder (ASD) is crucial to ensure optimal developmental outcomes for a substantial number of children with ASD in this region. This study evaluates the relevance and effectiveness of an evidence-based telementoring model Extension for Community Healthcare Outcomes (ECHO) Autism in increasing pediatricians' access to best-practice care for children with ASD in LMIC contexts. METHODS ECHO Autism was launched by a ‟hub" team of multidisciplinary ASD experts at a child development center in Mumbai, India. The culturally modified model included 13 biweekly sessions conducted annually using video-conferencing technology. Sessions combined expert-delivered didactics and facilitated case-based discussions on best-practice methods in screening, diagnosing, and managing autism and its comorbidities. Sixty-two physicians, including 59 pediatricians across 2 cohorts (2019-2020), participated in the mixed-methods study to evaluate participants' reactions, knowledge, behaviors, and impact on children and families. RESULTS Participants represented a broad geographic reach across India (n = 47) and other LMICs (n = 15). Both quantitative and qualitative data revealed high levels of participant satisfaction and improved knowledge and self-efficacy in ASD diagnosis and management. Qualitative themes highlighted the adult-learning processes of ECHO Autism that participants considered novel and beneficial, such as reflective discussions, respectful mentoring, having a parent as ‟expert," and cultural relevance, alongside changes in practice behaviors. CONCLUSION ECHO Autism clinics facilitated by local experts in LMICs can improve access to early diagnosis and evidence-based, comprehensive management for children with ASD and their families by positively influencing pediatricians' knowledge, attitudes, and practice behaviors.
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Myers RK, Labows C, Yerys BE, McDonald CC, Sartin EB, Mollen CJ, Curry AE. Transition to Adulthood for Autistic Adolescents: Topics Discussed by Healthcare Providers With Autistic Patients and Families. J Adolesc Health 2022; 70:829-832. [PMID: 35165029 PMCID: PMC9038620 DOI: 10.1016/j.jadohealth.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/07/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We surveyed healthcare providers to determine the extent to which they discuss transition-to-adulthood topics with autistic patients without intellectual disabilities. METHODS Seventy-four healthcare providers in the Philadelphia area reported on the patient age at which they begin transition conversations, topics covered, and provider comfort. We calculated the proportion of providers who endorsed each transition topic, overall and by clinical setting. RESULTS Providers initiated transition-related conversations at a median age of 16 years (IQR: 14, 18), with over half reporting they were "somewhat" or "a little" comfortable with discussions. Nearly all providers discussed at least one healthcare, well-being, and mental health topic, while basic need-related discussions were limited. DISCUSSION Results suggest providers may delay and feel poorly prepared to provide anticipatory guidance to autistic patients for transition to adulthood. Future efforts to enhance the available resources and preparation available to providers are essential to meet autistic patients' needs.
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Affiliation(s)
- Rachel K Myers
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Christina Labows
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin E Yerys
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Psychiatry, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Pediatrics, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emma B Sartin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia J Mollen
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allison E Curry
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Sohl K, Rynkiewicz A, Nanclares-Nogués V, Brewer Curran A, Scorah J, Steiman M, Lord C, Vasa RA, Słopień A, Janas-Kozik M, Łucka I, Mazur A. Project Extension for Community Health Outcomes (ECHO) Autism: A Successful Model to Increase Capacity in Community-Based Care. Brain Sci 2022; 12:brainsci12030327. [PMID: 35326283 PMCID: PMC8946611 DOI: 10.3390/brainsci12030327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 02/01/2023] Open
Abstract
Individuals with autism spectrum disorder (ASD) struggle to access high-quality health care due to the shortage of trained providers. ECHO (Extension for Community Healthcare Outcomes) Autism is a unique educational program that allows ASD experts to provide knowledge and skills to professionals in local communities to deliver evidence-based care to children with ASD and their families. The model teaches clinicians how to screen and diagnose ASD, as well as manage common co-occurring medical and mental health issues. ECHO Autism is particularly useful for addressing the complex needs of children with ASD and reducing disparities often present in rural and underserved communities. The model can be disseminated globally due to its flexibility in accommodating local and regional differences in social norms and constructs. This article provides an overview of the format of the ECHO Autism model, data supporting the model’s efficacy, and discusses future research directions.
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Affiliation(s)
- Kristin Sohl
- ECHO Autism Communities, Department of Child Health, University of Missouri School of Medicine, Columbia, MI 65211, USA; (K.S.); (V.N.-N.); (A.B.C.)
| | - Agnieszka Rynkiewicz
- Department of Psychiatry, College of Medical Sciences, University of Rzeszow, 35-956 Rzeszow, Poland
- Center for Diagnosis, Therapy and Education SPECTRUM ASC-MED, 80-404 Gdansk, Poland
- Correspondence:
| | - Valeria Nanclares-Nogués
- ECHO Autism Communities, Department of Child Health, University of Missouri School of Medicine, Columbia, MI 65211, USA; (K.S.); (V.N.-N.); (A.B.C.)
| | - Alicia Brewer Curran
- ECHO Autism Communities, Department of Child Health, University of Missouri School of Medicine, Columbia, MI 65211, USA; (K.S.); (V.N.-N.); (A.B.C.)
| | - Julie Scorah
- Montreal Neurological Institute-Hospital, Azrieli Centre for Autism Research McGill University, Montreal, QC H3A 2B4, Canada; (J.S.); (M.S.)
| | - Mandy Steiman
- Montreal Neurological Institute-Hospital, Azrieli Centre for Autism Research McGill University, Montreal, QC H3A 2B4, Canada; (J.S.); (M.S.)
| | - Catherine Lord
- Semel Institute for Neuroscience & Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Roma A. Vasa
- Center for Autism and Related Disorders, Kennedy Krieger Institute, John Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Agnieszka Słopień
- Department of Child and Adolescent Psychiatry, Poznan University of Medical Sciences, 61-701 Poznan, Poland;
| | - Małgorzata Janas-Kozik
- Department of Psychiatry and Psychotherapy, Medical University of Silesia, 40-635 Katowice, Poland;
- John Paul II Paediatric Centre, 41-218 Sosnowiec, Poland
| | - Izabela Łucka
- Department of Developmental Psychiatry, Psychotic and Geriatric Disorders, Medical University of Gdansk, 80-282 Gdansk, Poland;
| | - Artur Mazur
- Department of Paediatrics, Paediatric Endocrinology and Diabetes, College of Medical Sciences, University of Rzeszow, 35-959 Rzeszow, Poland;
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