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Van Dyke J, Rosenberg SA, Crume T, Reyes N, Alexander AA, Barger B, Fitzgerald R, Hightshoe K, Moody EJ, Pazol K, Rosenberg CR, Rubenstein E, Wiggins L, DiGuiseppi C. Child Age at Time of First Maternal Concern and Time to Services Among Children with Autism Spectrum Disorder. J Dev Behav Pediatr 2024:00004703-990000000-00167. [PMID: 38896561 DOI: 10.1097/dbp.0000000000001283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 04/15/2024] [Indexed: 06/21/2024]
Abstract
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.
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Affiliation(s)
- Julia Van Dyke
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Steven A Rosenberg
- Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tessa Crume
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nuri Reyes
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Aimee Anido Alexander
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Brian Barger
- Center for Leadership in Disability, School of Public Health, Georgia State University, Atlanta, GA
| | - Robert Fitzgerald
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO
| | - Kristina Hightshoe
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Eric J Moody
- Wyoming Institute for Disabilities, University of Wyoming, Laramie, WY
| | - Karen Pazol
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Cordelia R Rosenberg
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Eric Rubenstein
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Lisa Wiggins
- Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Carolyn DiGuiseppi
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
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Buck A, Hurewitz S, Franklin MS. Workforce perspective on racial and ethnic equity in early childhood autism evaluation and treatment: "The cornerstone of everything we do". AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024:13623613241235522. [PMID: 38477296 DOI: 10.1177/13623613241235522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
LAY ABSTRACT Black and non-White Latinx children tend to receive autism diagnoses later in life and with a higher degree of impairment than White children. The purpose of this study was to learn what is currently helping as well as preventing Black and non-White Latinx children from getting access to autism evaluation and services. We held virtual interviews with 26 experts who work with autistic children and their families, including clinical providers, researchers, advocates, and policymakers/government representatives. From these interviews, we identified four themes that have an impact on equity in autism services: (1) who makes up the workforce, (2) workforce capacity and accessibility, (3) workforce payment structure, and (4) changes due to the COVID-19 pandemic. These findings show the need for improved workforce diversity, autism-specific education, payment structures, and additional support for workforce members to avoid burnout. To make childhood autism services more equitable, diversity in recruitment across training levels, cultural awareness, increased autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow professionals in the field to better meet the needs of children and families from Black and non-White Latinx communities and achieve equity in early childhood autism services.
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Keehn RM, Swigonski N, Enneking B, Ryan T, Monahan P, Martin AM, Hamrick L, Kadlaskar G, Paxton A, Ciccarelli M, Keehn B. Diagnostic Accuracy of Primary Care Clinicians Across a Statewide System of Autism Evaluation. Pediatrics 2023; 152:e2023061188. [PMID: 37461867 PMCID: PMC10686684 DOI: 10.1542/peds.2023-061188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of the Early Autism Evaluation (EAE) Hub system, a statewide network that provides specialized training and collaborative support to community primary care providers in the diagnosis of young children at risk for autism spectrum disorder (ASD). METHODS EAE Hub clinicians referred children, aged 14 to 48 months, to this prospective diagnostic study for blinded follow-up expert evaluation including assessment of developmental level, adaptive behavior, and ASD symptom severity. The primary outcome was agreement on categorical ASD diagnosis between EAE Hub clinician (index diagnosis) and ASD expert (reference standard). RESULTS Among 126 children (mean age: 2.6 years; 77% male; 14% Latinx; 66% non-Latinx white), 82% (n = 103) had consistent ASD outcomes between the index and reference evaluation. Sensitivity was 81.5%, specificity was 82.4%, positive predictive value was 92.6%, and negative predictive value was 62.2%. There was no difference in accuracy by EAE Hub clinician or site. Across measures of development, there were significant differences between true positive and false negative (FN) cases (all Ps < .001; Cohen's d = 1.1-1.4), with true positive cases evidencing greater impairment. CONCLUSIONS Community-based primary care clinicians who receive specialty training can make accurate ASD diagnoses in most cases. Diagnostic disagreements were predominately FN cases in which EAE Hub clinicians had difficulty differentiating ASD and global developmental delay. FN cases were associated with a differential diagnostic and phenotypic profile. This research has significant implications for the development of future population health solutions that address ASD diagnostic delays.
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Affiliation(s)
| | - Nancy Swigonski
- Department of Pediatrics, Indiana University School of Medicine
| | - Brett Enneking
- Department of Pediatrics, Indiana University School of Medicine
| | - Tybytha Ryan
- Department of Pediatrics, Indiana University School of Medicine
| | - Patrick Monahan
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine
| | | | - Lisa Hamrick
- Department of Psychological Sciences, Purdue University
| | - Girija Kadlaskar
- Department of Speech, Language & Hearing Sciences, Purdue University
- MIND Institute, University of California Davis
| | - Angela Paxton
- Department of Pediatrics, Indiana University School of Medicine
| | - Mary Ciccarelli
- Department of Pediatrics, Indiana University School of Medicine
| | - Brandon Keehn
- Department of Speech, Language & Hearing Sciences, Purdue University
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Lewis S, Papadopoulos N, Mantilla A, Hiscock H, Whelan M, McGillivray J, Rinehart N. The impact of COVID-19 on sleep for autistic children: A systematic review. RESEARCH IN AUTISM SPECTRUM DISORDERS 2023; 102:102110. [PMID: 36713069 PMCID: PMC9868385 DOI: 10.1016/j.rasd.2023.102110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/21/2022] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Up to 80% of children with autism experience behavioural sleep problems, predominantly relating to bedtime resistance, sleep anxiety, sleep dysregulation, and shorter duration, which are associated with increased autistic symptom expression and emotional and behavioural difficulties. Researchers predicted the COVID-19 pandemic would worsen sleep and behavioural difficulties for autistic children, due to their need for routine and certainty. This systematic review is the first to focus on delineating the role of sleep disturbance in exacerbating autistic symptoms and internalising and externalising behaviours during the pandemic. METHOD In this PROSPERO registered systematic review, we aggregated and synthesised findings from empirical studies from 2020 onwards that included children with autism and examined sleep outcomes, using narrative and framework synthesis due to the variety of methods and designs employed. We identified additional relevant themes through inductive thematic analysis. RESULTS Seventy-one studies met the search criteria, and we selected seventeen for review following screening and quality assessment. These studies reported mixed findings; with strongest support for worsening of sleep problems typically experienced by autistic children, including difficulties with sleep regulation and shorter sleep duration. Further, sleep problems were associated with increased expression of autistic characteristics. CONCLUSIONS Preliminary findings of worsening sleep and increased autistic characteristics for autistic children throughout the COVID-19 pandemic highlight the need for ongoing, accessible and flexible service provision during exposure to environmental stressors. We propose that behavioural sleep interventions are well suited to telehealth adaptation and play an important role in supporting families when in-person treatment for sleep problems is not possible.
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Affiliation(s)
- Samantha Lewis
- Krongold Clinic, School of Educational Psychology and Counselling, Faculty of Education, Monash University, 19 Ancora-Imparo Way, Clayton, Victoria 3800, Australia
| | - Nicole Papadopoulos
- Krongold Clinic, School of Educational Psychology and Counselling, Faculty of Education, Monash University, 19 Ancora-Imparo Way, Clayton, Victoria 3800, Australia
| | - Ana Mantilla
- Krongold Clinic, School of Educational Psychology and Counselling, Faculty of Education, Monash University, 19 Ancora-Imparo Way, Clayton, Victoria 3800, Australia
| | - Harriet Hiscock
- Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia
| | - Moira Whelan
- Krongold Clinic, School of Educational Psychology and Counselling, Faculty of Education, Monash University, 19 Ancora-Imparo Way, Clayton, Victoria 3800, Australia
| | - Jane McGillivray
- School of Psychology, Faculty of Health, Deakin University, 1 Gheringhap Street, Geelong, Victoria 3220, Australia
| | - Nicole Rinehart
- Krongold Clinic, School of Educational Psychology and Counselling, Faculty of Education, Monash University, 19 Ancora-Imparo Way, Clayton, Victoria 3800, Australia
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Barbaresi W, Cacia J, Friedman S, Fussell J, Hansen R, Hofer J, Roizen N, Stein REK, Vanderbilt D, Sideridis G. Clinician Diagnostic Certainty and the Role of the Autism Diagnostic Observation Schedule in Autism Spectrum Disorder Diagnosis in Young Children. JAMA Pediatr 2022; 176:1233-1241. [PMID: 36251287 PMCID: PMC9577880 DOI: 10.1001/jamapediatrics.2022.3605] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/25/2022] [Indexed: 01/25/2023]
Abstract
Importance Autism spectrum disorder (ASD) affects 1 in 44 children. The Autism Diagnostic Observation Schedule (ADOS) is a semi-structured observation developed for use in research but is considered a component of gold standard clinical diagnosis. The ADOS adds time and cost to diagnostic assessments. Objective To evaluate consistency between clinical diagnosis (index ASD diagnosis) and diagnosis incorporating the ADOS (reference standard ASD diagnosis) and to examine clinician and child factors that predict consistency between index diagnoses and reference standard diagnoses. Design, Setting, and Participants This prospective diagnostic study was conducted between May 2019 and February 2020. Developmental-behavioral pediatricians (DBPs) made a diagnosis based on clinical assessment (index ASD diagnosis). The ADOS was then administered, after which the DBP made a second diagnosis (reference standard ASD diagnosis). DBPs self-reported diagnostic certainty at the time of the index diagnoses and reference standard diagnoses. The study took place at 8 sites (7 US and 1 European) that provided subspecialty assessments for children with concerns for ASD. Participants included children aged 18 months to 5 years, 11 months, without a prior ASD diagnosis, consecutively referred for possible ASD. Among 648 eligible children, 23 refused, 376 enrolled, and 349 completed the study. All 40 eligible DBPs participated. Exposures ADOS administered to all child participants. Main Outcomes and Measures Index diagnoses and reference standard diagnoses of ASD (yes/no). Results Among the 349 children (279 [79.7%] male; mean [SD] age, 39.9 [13.4] months), index diagnoses and reference standard diagnoses were consistent for 314 (90%) (ASD = 250; not ASD = 64) and changed for 35. Clinician diagnostic certainty was the most sensitive and specific predictor of diagnostic consistency (area under curve = 0.860; P < .001). In a multilevel logistic regression, no child or clinician factors improved prediction of diagnostic consistency based solely on clinician diagnostic certainty at time of index diagnosis. Conclusions and Relevance In this prospective diagnostic study, clinical diagnoses of ASD by DBPs with vs without the ADOS were consistent in 90.0% of cases. Clinician diagnostic certainty predicted consistency of index diagnoses and reference standard diagnoses. This study suggests that the ADOS is generally not required for diagnosis of ASD in young children by DBPs and that DBPs can identify children for whom the ADOS may be needed.
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Affiliation(s)
- William Barbaresi
- Division of Developmental Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jaclyn Cacia
- Division of Developmental and Behavioral Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandra Friedman
- University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora
| | - Jill Fussell
- University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock
| | - Robin Hansen
- University of California, Davis, School of Medicine, MIND Institute, Sacramento
| | - Johannes Hofer
- Research Institute for Developmental Medicine, Johannes Kepler University, Institute for Neurology of the Senses and Language, Hospital of St John of God, Linz, Austria
| | - Nancy Roizen
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio
| | - Ruth E. K. Stein
- Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx, New York
| | - Douglas Vanderbilt
- Division of Developmental-Behavioral Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
- Division of General Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
| | - Georgios Sideridis
- Division of Developmental Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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McNally Keehn R, Enneking B, James C, Tang Q, Rouse M, Hines E, Raches C, Etling A. Telehealth Evaluation of Pediatric Neurodevelopmental Disabilities During the COVID-19 Pandemic: Clinician and Caregiver Perspectives. J Dev Behav Pediatr 2022; 43:262-272. [PMID: 34954761 DOI: 10.1097/dbp.0000000000001043] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to present clinician and caregiver perspectives regarding telehealth neurodevelopmental evaluation delivered at the onset of the coronavirus disease 2019 (COVID-19) pandemic. Specifically, we sought to describe telehealth neurodevelopmental evaluations, examine associations between child characteristics and diagnostic factors, determine the impact of technology and family barriers, and report on clinician and caregiver satisfaction with telehealth evaluation. METHODS In response to the COVID-19 pandemic, in-person clinical services at a large children's hospital neurodevelopmental clinic were transitioned to telehealth. Data are presented for 254 remote evaluations of children (18-212 months; referral concern: 51% autism spectrum disorder [ASD], 24% developmental delay/intellectual disability, 25% other neurodevelopmental concern) conducted from May to July 2020. Data were gathered from electronic health records as well as clinician and caregiver surveys. RESULTS A clinical diagnosis was provided in 72% of telehealth evaluations. Clinicians rated diagnostic certainty as "completely" or "somewhat" certain in 74% of evaluations. Certainty ratings were higher for evaluations in which a diagnosis of ASD was provided. Although technology and family challenges were reported, clinicians rarely identified these as disruptive to the evaluation process. Clinicians reported satisfaction with various aspects of delivering telehealth. Caregivers endorsed high satisfaction with receipt of telehealth and reduced travel burden. CONCLUSION The COVID-19 pandemic has rapidly transformed service delivery for individuals with neurodevelopmental disabilities and provided an unprecedented opportunity to evaluate the deployment of telehealth evaluation to meet the need for ongoing diagnostic care. Our findings suggest that telehealth holds significant promise for neurodevelopmental assessment both within the context of a global pandemic and beyond.
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Affiliation(s)
| | | | | | - Qing Tang
- Biostatistics, Indiana University School of Medicine, Indianapolis, IN
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