Practitioner Perceptions of the Assessment and Diagnosis of Autism in Australia

Who Is Attending? The Role of Child Ethnicity and Maternal Demographics in Research Engagement and Early Identification of Autism

Inequitable access to early autism developmental surveillance is evident globally. However, there is limited research examining autism diagnosis, ethnicity, and community profiles when engaging in research for the early identification of autism. We aimed to understand the relationships between child ethnicity, maternal demographics, and autism diagnosis, comparing retrospective data from the 2016 census for eight local government areas (LGAs) in Victoria, Australia. Maternal and child health (MCH) nurses monitored 13,511 children under 42 months for the early signs of autism using the Social Attention Communication Surveillance-Revised (SACS-R) and SACS-R Preschool (SACS-PR) tools during well-child checks. Of these, 340 children with a "high likelihood" of autism attended developmental assessments. Participants' maternal ethnicity ('European maternal ethnicity', EME; 'non-European maternal ethnicity,' N-EME; 'mixed maternal ethnicity,' MME'), socioeconomic factors, and autism prevalence were compared to their LGA community. Results indicated that study participants were representative of their LGA communities, though bi- and multilingualism was higher in our cohort. Differences in current maternal employment, maternal education, annual family income, and autism prevalence were found between the N-EME, EME, and MME groups. Our study found that research engagement was driven by maternal education, maternal employment, and annual family income, and further research is required to understand these relationships.

A survey of assessment practices among health professionals diagnosing females with autism

BACKGROUND

Emerging research suggests there may be a distinct female autism phenotype, although females are still diagnosed at a much lower rate than males. To date, no research has examined the assessment practices of health professionals when assessing females for autism.

AIMS

This study aimed to identify the training received, level of confidence, and assessment practices specific to assessing females for autism.

METHODS AND PROCEDURE

An online survey was completed by 126 health professionals (34 paediatricians, 40 psychologists and 52 speech pathologists) working across Australia.

OUTCOMES AND RESULTS

The majority of health professionals received no training that addressed gender differences when assessing for autism, even when controlling for number of years since they completed their studies. Most health professionals reported using similar assessment practices when assessing and diagnosing males and females for autism; only 18.2 % reported using female-specific assessment measures.

CONCLUSIONS AND IMPLICATIONS

Suggestions for the lack of difference in assessment measures used across genders are discussed. Potential for including measures that may be more sensitive to the presentation of autism in females in health professional's assessment practices is identified. The high proportion of health professionals engaging in professional development following their clinical training highlights the importance of training opportunities to enhance practitioner understanding and confidence when undertaking assessments for autism in females.

Parent experiences of obtaining an autism diagnosis for their daughter: An interpretative phenomenological analysis

LAY ABSTRACT

Autistic females are often diagnosed later than males and are also more likely to be misdiagnosed with other conditions. Co-occurring conditions may also be diagnosed at the time of the assessment but their autism diagnosis is missed. The majority of research examining the parent experience of obtaining an autism diagnosis for their child has included predominantly or exclusively male children in their samples. This study examines the experiences of parents in obtaining an autism diagnosis for their daughters in Australia through interview data which allowed for an exploration of their lived experiences. Several of the parents reported positive feelings of excitement or curiosity in relation to the assessment process which are emotions that have not been reported in earlier studies. While recent research advances have improved our understanding of gender differences in autistic behaviours, the findings of this study suggest that some practitioners have obsolete knowledge which may lead to misdiagnosis or missed diagnosis in some females. Although the extent that these experiences are representative of parents in the wider community is unknown, the fact that they are still being reported in the present day suggests that a proportion of health professionals continue to practice with outdated conceptualisations of autism.

Cost-Effectiveness of Care Coordination for Children With Chronic Noncomplex Medical Conditions: Results From a Multicenter Randomized Clinical Trial

OBJECTIVES

To assess the cost-effectiveness of care coordination, compared with standard care, for children with chronic noncomplex medical conditions.

METHODS

A total of 81 children aged between 2 and 15 years newly diagnosed with a noncomplex chronic condition were randomized to either care coordination or standard care as part of a multicenter randomized controlled trial. Families receiving care coordination were provided access to an Allied Health Liaison Officer, who facilitated family-centered healthcare access across hospital, education, primary care, and community sectors. Costs were estimated over a 12-month period from the perspective of the Australian health system. Health outcomes were valued as quality-adjusted life-years (QALYs). Caregiver productivity costs were included in an alternative base-case analysis, and key assumptions were tested in a series of one-way sensitivity analyses. A probabilistic sensitivity analysis was conducted to investigate the overall impact of uncertainty in the data.

RESULTS

Children in the intervention arm incurred an average of $17 in additional health system costs (95% confidence interval -3861 to 1558) and gained an additional 0.031 QALYs (95% confidence interval -0.29 to 0.092) over 12 months, producing an incremental cost-effectiveness ratio of $548 per QALY. When uncertainty was considered, there was a 73% likelihood that care coordination was cost-effective from a health system perspective, assuming a willingness to pay of $50 000 per QALY. This increased to 78% when caregiver productivity costs were included.

CONCLUSIONS

Care coordination is likely to be a cost-effective intervention for children with chronic noncomplex medical conditions in the Australian healthcare setting.

Exploring the Experience of Seeking an Autism Diagnosis as an Adult

Background

Emerging research suggests that seeking an autism diagnosis as an adult is usually difficult and time-consuming but brings relief once a diagnosis is made. This study explored the experience of the pathway to an autism diagnosis during adulthood for adults living in Australia.

Methods

We conducted a qualitative phenomenological study and interviewed 13 adults who identified as autistic about their pathway to autism diagnosis in their mode of choice. Spoken interviews were transcribed verbatim, and transcripts were analyzed by using a thematic approach.

Results

Data analysis resulted in 6 themes and 20 meaning units that described the experiences of adults seeking an autism diagnosis in Australia. These themes involved two interwoven journeys that spanned before, during, and after the diagnostic process. The personal journey involved feeling different, considering autism, and living as autistic, whereas the clinical journey involved missed opportunities, varied diagnostic experiences, and absent supports.

Conclusions

Given the potential benefits for adults obtaining a formal autism diagnosis and accessing post-diagnostic supports, it is important that health professionals and governments collaborate to reduce access barriers and ensure adequate services are available. The findings from this study informed the development of Australia's national guideline for autism diagnosis.

Coaching While Waiting for Autism Spectrum Disorder Assessment: A Pilot Feasibility Study for a Randomized Controlled Trial on Occupational Performance Coaching and Service Navigation

Aim

To determine whether short-phase Occupational Performance Coaching combined with service navigation support is feasible for families waiting for autism assessment.

Method

A pilot feasibility study was conducted using a blinded randomization procedure that allocated participants to one of three trial arms: (1) face-to-face coaching, (2) videoconference coaching, and (3) usual care. Outcomes included a retention aim of 70–80%, goal attainment and secondary standardised measures of adaptive behaviour, social skills, parenting stress, service access and family quality of life.

Results

Caregivers and children (n = 16, child mean age of 3 years 7 months) were recruited following referral for an autism assessment. Retention was 75%, with change scores in performance and satisfaction of selected goals higher in the intervention groups than the usual care group.

Interpretation

Findings support progression to a future randomized controlled trial assessing intervention efficacy.

Choose your Own Adventure: Pathways to Adulthood Autism Diagnosis in Australia

Pathways to diagnosis in adulthood are poorly understood. Even less is known about undiagnosed adults who believe they may be autistic. This mixed-methods online survey examined adults' journeys from initial concern to receiving the diagnosis. Quantitative findings showed the diagnostic process to be highly heterogeneous. Qualitative analysis identified desires for explanation and support as motives for seeking diagnosis. Cost and fear of not being taken seriously were major barriers, echoed by qualitative responses that described the process as confusing, expensive and time-consuming. While most participants were satisfied with the diagnosis, their emotional reactions were complex. Findings support the need for thoroughly implementing national guidelines, and for improved knowledge and communication in mainstream clinicians encountering clients with possible autism characteristics.

Autism diagnosis as a social process

LAY ABSTRACT

When a child or adult is referred for an autism diagnosis, clinicians from different backgrounds work together to make a diagnostic decision. A few studies have asked clinicians in interview how they feel about diagnosis and what the challenges are. We interviewed clinicians in child and adult assessment services in England, and from different professional backgrounds, about the challenges of autism diagnosis and the factors that might influence the assessment process. We found that there were a number of challenges in autism diagnosis, especially when someone coming for diagnosis was considered to be near the diagnostic threshold. Clinicians told us that making a diagnosis was like creating a 'narrative': looking at many different factors that told a story about a person, rather than just looking at the results of diagnostic tests. Clinicians do not always agree with the results of those tests and have to use their specialist clinical judgement to make decisions. Clinicians were concerned about the amount of time people have to wait for an autism assessment, and the resulting pressure on the assessment process. The findings of this work can help us to understand how diagnosis happens and consider ways in which it can be improved for adults, children and families coming for assessment, as well as clinicians.

The Feedback Session of an Autism Assessment: A Scoping Review of Clinical Practice Guideline Recommendations

This review aimed to assess the quality and content of recommendations for delivering an autism diagnosis, published internationally within clinical practice guidelines. Seventeen relevant guidelines were identified. When methodological information was provided, recommendations for feedback were predominantly formed through consensus. Recommendations consistently included who should attend feedback, the timing and mode of delivery, the clinician's manner, and what should be discussed and/or included in an accompanying report. Specific recommendations were not consistent however, and a number of gaps were identified, such as the inclusion of educators and educational specific recommendations. Although individual variation is necessary for autism diagnosis disclosure, agreement on minimum standards of practice is warranted. Further investigation is required to establish best practice.

Experiences of fathers regarding the diagnosis of their child with autism spectrum disorder: A narrative review of the international research

AIM AND OBJECTIVES

The aim of this systematic review was to identify the views and experiences of fathers regarding their child's Autism Spectrum Disorder diagnosis.

BACKGROUND

The diagnosis of a child's Autism Spectrum Disorder may be a stressful experience, creating uncertainty for parents. There has been a limited research focus on the views and experiences of fathers in relation to the diagnosis of Autism Spectrum Disorder of their child.

DESIGN

A systematic literature review of quantitative, qualitative and mixed-methods research studies.

DATA SOURCES

Academic Search Complete, CINAHL, MEDLINE and PsycINFO.

METHODS

From August to October 2020, two authors independently performed a systematic data extraction and appraised the studies using a recognised instrument. The PRISMA checklist was used in the review.

RESULTS

Nine papers met the inclusion criteria. Four themes emerged: (a) gradual recognition of developmental delay, (b) an emotional time, (c) coping and adaptation and (d) ongoing adjustments to the fathering role.

CONCLUSIONS

Nurses and other professionals need to work collaboratively with fathers to improve their experiences and provide supports at the time of Autism Spectrum Disorder diagnosis.

Coaching While Waiting for Autism Spectrum Disorder Assessment: Protocol of a Pilot Feasibility Study for a Randomized Controlled Trial on Occupational Performance Coaching and Service Navigation Support

BACKGROUND

In Australia, the average time between a first concern of autism spectrum disorder (ASD) and diagnosis is over 2 years. After referral for assessment, families often wait 6-12 months before their appointment. This can be a time of uncertainty and stress for families. For some families, other forms of assistance are not accessible and thus timely intervention opportunities are missed. There is little evidence about how to provide the best support for children or caregivers while on assessment waiting lists.

OBJECTIVE

The aim of this study is to determine whether use of a coaching intervention called Occupational Performance Coaching (OPC) combined with service navigation support is feasible for families waiting for ASD assessment, as a crucial first step in planning a randomized controlled trial.

METHODS

A pilot and feasibility study will be conducted using recommended constructs and associated measures, which will be reported using CONSORT (Consolidated Standards or Reporting Trials) guidance. Participants will be child and caregiver dyads or triads, recruited within 4 months of their child (aged 1-7 years) being referred to one of two services for an ASD assessment in Victoria, Australia. A blinded randomization procedure will be used to allocate participants to one of three trial arms: (1) coaching and support intervention delivered face to face, (2) coaching and support intervention via videoconference, and (3) usual care. Descriptive statistics will be used to describe the sample characteristics of parents and children, inclusive of service access at baseline and follow up. Recruitment rates will be reported, and retention rates will be evaluated against a predicted rate of 70%-80% in each intervention arm. Goal attainment, using the Canadian Occupational Performance Measure, will indicate preliminary evidence for efficacy within the intervention arms, with an increase of 2 or more points on a 10-point performance and satisfaction scale considered clinically significant.

RESULTS

The study was approved by The Royal Children's Hospital Research Ethics and Governance Department in September 2018. As of October 2020, 16 families have been recruited to the study. Data analysis is ongoing and results are expected to be published in 2021.

CONCLUSIONS

Study findings will support planning for a future randomized controlled trial to assess the efficacy of OPC and service navigation support for caregivers of children awaiting ASD assessment.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620000164998; www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378793&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20011.

Parents' experiences of the service pathway to an autism diagnosis for their child: What predicts an early diagnosis in Australia?

BACKGROUND

The early identification and diagnosis of autism is critical to ensure access to appropriate early intervention and support. Few studies have examined the association between potentially modifiable characteristics of the service system and timelier diagnosis.

METHODS

An online survey was conducted to examine parental experiences of service pathways to an autism diagnosis for their child, and to identify child, family, and service level characteristics that predict the age and timeliness of diagnosis. Participants included 107 parents of children with autism who were diagnosed by 7 years of age and a smaller subgroup of 29 parents who were diagnosed after 7 years of age.

RESULTS

Parents of younger children reported that, on average, it took approximately 12 months and 8 professional consultations to receive a confirmed diagnosis for their child. Parents of older children, as well as those who reported they were a sole caregiver, or were advised by professionals to 'wait and see', reported more time between first raising concerns and diagnosis.

CONCLUSIONS

The findings reiterate the importance of proactive professional responses to parental concerns. They also highlight the need for standardised screening and assessment and professional development and training to build capacity in the sector to deliver timely and accurate autism diagnoses.

Study protocol for an evaluation of ASDetect - a Mobile application for the early detection of autism

Background

Autism Spectrum Conditions (ASC) can be reliably diagnosed by 24 months of age. However, despite the well-known benefits of early intervention, there is still a research-practice gap in the timely identification of ASC, particularly in low-resourced settings. The Social Attention and Communication Surveillance (SACS) tool, which assesses behavioural markers of autism between 12 to 24 months of age, has been implemented in Maternal and Child Health (MCH) settings, with excellent psychometric properties. ASDetect is a free mobile application based on the SACS, which is designed to meet the need for an effective, evidence-based tool for parents, to learn about children’s early social-communication development and assess their child’s ‘likelihood’ for ASC.

Study aims

The primary aim of this study is to evaluate the psychometric properties of ASDetect in the early detection of children with ASC. A secondary aim is to assess ASDetect’s acceptability and parental user experience with the application.

Methods

Families are recruited to download the application and participate in the study via social media, health professionals (e.g., MCH nurses, paediatricians) and word of mouth. All participating caregivers complete a demographic questionnaire, survey regarding their user experience, and the Social Responsiveness Scale-2 (SRS-2), an autism screening questionnaire; they are also invited to participate in focus groups. Children identified at ‘high likelihood’ for ASC based on the ASDetect results, the SRS-2 or parental and/or professional concerns undergo a formal, gold-standard, diagnostic assessment. Receiver Operating Characteristic analyses will be used to assess psychometric properties of ASDetect. Thematic analyses will be used to explore themes arising in the focus groups to provide insights regarding user experiences with the app. Multiple regression analyses will be carried out to determine the extent to which demographic factors, parental stress and beliefs on health surveillance and child results on ASDetect are associated with the parental user-experience of the application.

Discussion

With a strong evidence-base and global access, ASDetect has the potential to empower parents by providing them with knowledge of their child’s social-communication development, validating and reassuring any parental concerns, and supporting them in communicating with other health professionals, ultimately enhancing child and family outcomes and well-being.

The Quality of Care for Australian Children with Autism Spectrum Disorders

Knowledge about the quality of care delivered to children with autism spectrum disorders (ASD) in relation to that recommended by clinical practice guidelines (CPGs) is limited. ASD care quality indicators were developed from CPGs and validated by experts, then used to assess the quality of care delivered by general practitioners (GPs) and pediatricians in Australia. Data were retrospectively collected from the medical records of 228 children (≤ 15 years) with ASD for 2012-2013. Overall quality of care was high, but with considerable variation among indicators, and between GPs and pediatricians-e.g., GPs were less likely to complete the assessment care bundle (61%; 95% CI 21-92). Findings highlight potential areas for improvement in the need for standardized criteria for diagnosis.

An evaluation of community pharmacists’ understanding of autism spectrum disorder: a cross-sectional study in Western Australia

Objectives

To assess the knowledge and understanding of autism spectrum disorder (ASD) by community pharmacists, across Western Australia (WA) and evaluate the extent to which they incorporate ASD friendly practices in their pharmacy.

Methods

A cross-sectional study involved a postal questionnaire sent to a stratified random sample of 250 community pharmacies across WA. A score of ≥10/13 (≥76.9%) appropriate responses to selected questions was considered an indication of ‘good knowledge’ of ASD. Univariate associations between ‘good knowledge’ and variables in the questionnaire were analysed using chi-square statistics, and multivariate analysis was performed using a logistic regression model. Demographic data relating to the pharmacy were used to determine the likelihood it was ASD friendly.

Key findings

Overall, 97/250 (38.8%) questionnaires were returned. There were 34/96 (35.4%) respondents classified as having ‘good knowledge’. Stigma surrounding ASD was the single best indicator of ‘good knowledge’ (P < 0.0001). None of the respondents indicated they catered specifically for ASD, and 38/97 (39.2%) reported that no changes were needed to their pharmacy to improve accessibility. There were a number of demographic features that increased the likelihood that pharmacies had the potential to be ASD friendly.

Conclusions

Pharmacists overall had a basic understanding of ASD. Pharmacists who identified that stigma surrounding ASD existed in the community were more likely to achieve ‘good knowledge’. There was a reluctance to improve pharmacy accessibility to patients with ASD. Pharmacists did not appear to incorporate ASD beneficial practices into their pharmacy and pharmacy environment.

Understanding psychiatrists' knowledge, attitudes and experiences in identifying and supporting their patients on the autism spectrum: online survey

BACKGROUND

Psychiatrists play a critical role in identifying and supporting their patients on the autism spectrum in the UK, yet little is known about their knowledge, attitudes and experiences in this regard.

AIMS

To understand psychiatrists' experiences of working with autistic individuals, their confidence in making diagnostic/management decisions and the factors that affect such decisions.

METHOD

A total of 172 psychiatrists took part in an online self-report survey.

RESULTS

Most psychiatrists reported receiving useful training on autism and were knowledgeable about the condition, particularly those with a personal connection to autism. Higher confidence in working with autistic patients was linked to greater levels of autism knowledge, experience and training. Several systemic and autism-specific factors were highlighted by psychiatrists, which were felt to challenge their ability to provide effective care and support for their patients on the autism spectrum.

CONCLUSIONS

Psychiatrists' views corroborated previous research with the autism community, highlighting the need to co-design services that are accessible, respectful and person-centred.

DECLARATION OF INTEREST

I.D. is the Royal College of Psychiatrists' Autism Champion.

Autism Diagnosis in the United Kingdom: Perspectives of Autistic Adults, Parents and Professionals

Accessing an autism diagnosis is a key milestone, both for an individual and their family. Using a qualitative methodology, the current study examined the views and experiences of ten autistic adults, ten parents of children on the autism spectrum, and ten professionals involved in autism diagnosis, all based in the United Kingdom (UK). Interviewing these 30 respondents about the diagnostic process and subsequent support options, the goal was to identify aspects of the diagnostic process that are working well, and areas in which improvements are needed. Using thematic analysis, three key themes were identified: the process of understanding and accepting autism; multiple barriers to satisfaction with the diagnostic process; and inadequate post-diagnostic support provision.