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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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Davis JM, Harrington MB, Howie FR, Mohammed KS, Gunderson JA. Reducing Time to Diagnosis of Autism Spectrum Disorder Using an Integrated Community Specialty Care Model: A Retrospective Study. J Pediatr 2024; 270:114009. [PMID: 38492915 DOI: 10.1016/j.jpeds.2024.114009] [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] [Received: 09/13/2023] [Revised: 03/07/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To evaluate a fast-track triage model in an integrated community specialty clinic to reduce the age of diagnosis for patients with autism spectrum disorder (ASD). STUDY DESIGN A retrospective chart review was performed for patients seen in an integrated community specialty pediatric practice using a fast-track screening and triage model. The percentage of ASD diagnoses, age at diagnosis, and time from referral to diagnosis were evaluated. The fast-track triage model was compared with national and statewide estimates of median age of first evaluation and diagnosis. RESULTS From January 1, 2020, through December 31, 2021, 189 children with a mean (SD) age of 32.2 (12.4) months were screened in the integrated community specialty. Of these, 82 (43.4%) children were referred through the fast-track triage for further evaluation in the developmental and behavioral pediatrics (DBP) department, where 62 (75.6%) were given a primary diagnosis of ASD. Average wait time from referral to diagnosis using the fast-track triage model was 6 months. Mean (SD) age at diagnosis was 37.7 (13.5) months. The median age of diagnosis by the fast-track triage model was 33 months compared with the national and state median ages of diagnosis at 49 and 59 months, respectively. CONCLUSIONS With the known workforce shortage in fellowship-trained developmental behavioral pediatricians, the fast-track triage model is feasible and maintains quality of care while resulting in more timely diagnosis, and reducing burden on DBP by screening out cases who did not require further multidisciplinary DBP evaluation as they were appropriately managed by other areas.
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Affiliation(s)
- Jessica M Davis
- Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Molly B Harrington
- Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Flora R Howie
- Division of Developmental-Behavioral Pediatrics, Mayo Clinic, Rochester, MN
| | - Khaled S Mohammed
- Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Jaclyn A Gunderson
- Division of Developmental-Behavioral Pediatrics, Mayo Clinic, Rochester, MN.
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Gerdts J, Casagrande KA, Bateman KJ, Hudac CM, Bravo A, Mancini J, Mannheim J, Ogata B, Orville K, Stobbe GA. ECHO Autism Washington: Autism Diagnostic Evaluations in Primary Care. Clin Pediatr (Phila) 2024:99228241255866. [PMID: 38828759 DOI: 10.1177/00099228241255866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
ECHO (Extensions for Community Healthcare Outcomes) Autism is a telementoring learning model to increase community capacity for autism-related health care. Seventy-seven pediatric providers (mostly primary care, seeing exclusively Medicaid patient populations) enrolled in 1 year of ECHO Autism Washington. Analysis of self-report surveys showed a significant increase in autism diagnoses made by ECHO providers after 1 year, F(1, 65) = 7.52, P = .008. Providers who attended more sessions reported making more diagnoses, F(2, 613.26), P = .045. Of note, autism diagnoses were not externally validated. The total number of reported barriers reduced, F(2, 61) = 13.5), P < .001, and confidence ratings increased F(2, 60) = 24.21, P < .001. The average number of diagnostic referrals from ECHO providers to the state's largest autism specialty clinic significantly reduced, t(43) = 4.23, P < .001, with significantly fewer diagnostic referrals made during and after ECHO training compared with a comparison group of 28 non-ECHO providers, t(58.77) = -3.36, P < .001. Overall, 1 year of ECHO Autism Washington participation led to significant changes in autism diagnostic practices.
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Affiliation(s)
- Jennifer Gerdts
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Karís A Casagrande
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | | - Caitlin M Hudac
- Department of Psychology, Carolina Autism and Neurodevelopment Research Center, University of South Carolina, Columbia, SC, USA
| | - Alice Bravo
- College of Education, University of Washington, Seattle, WA, USA
| | - James Mancini
- Institute on Human Development and Disability, University of Washington, Seattle, WA, USA
| | | | - Beth Ogata
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kate Orville
- Institute on Human Development and Disability, University of Washington, Seattle, WA, USA
| | - Gary A Stobbe
- Department of Neurology, University of Washington, Seattle, WA, USA
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Keehn B, Monahan P, Enneking B, Ryan T, Swigonski N, McNally Keehn R. Eye-Tracking Biomarkers and Autism Diagnosis in Primary Care. JAMA Netw Open 2024; 7:e2411190. [PMID: 38743420 PMCID: PMC11094561 DOI: 10.1001/jamanetworkopen.2024.11190] [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] [Received: 11/20/2023] [Accepted: 03/12/2024] [Indexed: 05/16/2024] Open
Abstract
Importance Finding effective and scalable solutions to address diagnostic delays and disparities in autism is a public health imperative. Approaches that integrate eye-tracking biomarkers into tiered community-based models of autism evaluation hold promise for addressing this problem. Objective To determine whether a battery of eye-tracking biomarkers can reliably differentiate young children with and without autism in a community-referred sample collected during clinical evaluation in the primary care setting and to evaluate whether combining eye-tracking biomarkers with primary care practitioner (PCP) diagnosis and diagnostic certainty is associated with diagnostic outcome. Design, Setting, and Participants Early Autism Evaluation (EAE) Hub system PCPs referred a consecutive sample of children to this prospective diagnostic study for blinded eye-tracking index test and follow-up expert evaluation from June 7, 2019, to September 23, 2022. Participants included 146 children (aged 14-48 months) consecutively referred by 7 EAE Hubs. Of 154 children enrolled, 146 provided usable data for at least 1 eye-tracking measure. Main Outcomes and Measures The primary outcomes were sensitivity and specificity of a composite eye-tracking (ie, index) test, which was a consolidated measure based on significant eye-tracking indices, compared with reference standard expert clinical autism diagnosis. Secondary outcome measures were sensitivity and specificity of an integrated approach using an index test and PCP diagnosis and certainty. Results Among 146 children (mean [SD] age, 2.6 [0.6] years; 104 [71%] male; 21 [14%] Hispanic or Latine and 96 [66%] non-Latine White; 102 [70%] with a reference standard autism diagnosis), 113 (77%) had concordant autism outcomes between the index (composite biomarker) and reference outcomes, with 77.5% sensitivity (95% CI, 68.4%-84.5%) and 77.3% specificity (95% CI, 63.0%-87.2%). When index diagnosis was based on the combination of a composite biomarker, PCP diagnosis, and diagnostic certainty, outcomes were concordant with reference standard for 114 of 127 cases (90%) with a sensitivity of 90.7% (95% CI, 83.3%-95.0%) and a specificity of 86.7% (95% CI, 70.3%-94.7%). Conclusions and Relevance In this prospective diagnostic study, a composite eye-tracking biomarker was associated with a best-estimate clinical diagnosis of autism, and an integrated diagnostic model including PCP diagnosis and diagnostic certainty demonstrated improved sensitivity and specificity. These findings suggest that equipping PCPs with a multimethod diagnostic approach has the potential to substantially improve access to timely, accurate diagnosis in local communities.
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Affiliation(s)
- Brandon Keehn
- Department of Speech, Language, and Hearing Sciences, Purdue University, West Lafayette, Indiana
- Department of Psychological Sciences, Purdue University, West Lafayette, Indiana
| | - Patrick Monahan
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Brett Enneking
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Tybytha Ryan
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Nancy Swigonski
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
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Hrdlicka M, Urbanek T, Rotreklova A, Kultova A, Valek O, Dudova I. Predictors of age at diagnosis in autism spectrum disorders: the use of multiple regression analyses and a classification tree on a clinical sample. Eur Child Adolesc Psychiatry 2024; 33:1171-1177. [PMID: 36933152 PMCID: PMC10024300 DOI: 10.1007/s00787-023-02189-6] [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: 10/11/2022] [Accepted: 03/08/2023] [Indexed: 03/19/2023]
Abstract
The increasing prevalence of autism spectrum disorders (ASD) has led to worldwide interest in factors influencing the age of ASD diagnosis. Parents or caregivers of 237 ASD children (193 boys, 44 girls) diagnosed using the Autism Diagnostic Observation Schedule (ADOS) completed a simple descriptive questionnaire. The data were analyzed using the variable-centered multiple regression analysis and the person-centered classification tree method. We believed that the concurrent use of these two methods could produce robust results. The mean age at diagnosis was 5.8 ± 2.2 years (median 5.3 years). Younger ages for ASD diagnosis were predicted (using multiple regression analysis) by higher scores in the ADOS social domain, higher scores in ADOS restrictive and repetitive behaviors and interest domain, higher maternal education, and the shared household of parents. Using the classification tree method, the subgroup with the lowest mean age at diagnosis were children, in whom the summation of ADOS communication and social domain scores was ≥ 17, and paternal age at the delivery was ≥ 29 years. In contrast, the subgroup with the oldest mean age at diagnosis included children with summed ADOS communication and social domain scores < 17 and maternal education at the elementary school level. The severity of autism and maternal education played a significant role in both types of data analysis focused on age at diagnosis.
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Affiliation(s)
- Michal Hrdlicka
- Department of Child Psychiatry, Second Faculty of Medicine, Charles University, University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic.
- Institute of Psychology, Faculty of Arts, Masaryk University, Brno, Czech Republic.
| | - Tomas Urbanek
- Institute of Psychology, Academy of Sciences, Brno, Czech Republic
| | - Adela Rotreklova
- Department of Child Psychiatry, Second Faculty of Medicine, Charles University, University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
| | - Aneta Kultova
- Military University Hospital, Prague, Czech Republic
| | - Ondrej Valek
- Military University Hospital, Prague, Czech Republic
| | - Iva Dudova
- Department of Child Psychiatry, Second Faculty of Medicine, Charles University, University Hospital Motol, V Uvalu 84, 15006, Prague, Czech Republic
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Sano M, Hirosawa T, Yoshimura Y, Hasegawa C, An KM, Tanaka S, Yaoi K, Naitou N, Kikuchi M. Neural responses to syllable-induced P1m and social impairment in children with autism spectrum disorder and typically developing Peers. PLoS One 2024; 19:e0298020. [PMID: 38457397 PMCID: PMC10923473 DOI: 10.1371/journal.pone.0298020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 01/17/2024] [Indexed: 03/10/2024] Open
Abstract
In previous magnetoencephalography (MEG) studies, children with autism spectrum disorder (ASD) have been shown to respond differently to speech stimuli than typically developing (TD) children. Quantitative evaluation of this difference in responsiveness may support early diagnosis and intervention for ASD. The objective of this research is to investigate the relationship between syllable-induced P1m and social impairment in children with ASD and TD children. We analyzed 49 children with ASD aged 40-92 months and age-matched 26 TD children. We evaluated their social impairment by means of the Social Responsiveness Scale (SRS) and their intelligence ability using the Kaufman Assessment Battery for Children (K-ABC). Multiple regression analysis with SRS score as the dependent variable and syllable-induced P1m latency or intensity and intelligence ability as explanatory variables revealed that SRS score was associated with syllable-induced P1m latency in the left hemisphere only in the TD group and not in the ASD group. A second finding was that increased leftward-lateralization of intensity was correlated with higher SRS scores only in the ASD group. These results provide valuable insights but also highlight the intricate nature of neural mechanisms and their relationship with autistic traits.
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Affiliation(s)
- Masuhiko Sano
- Department of Psychiatry and Neurobiology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Tetsu Hirosawa
- Department of Psychiatry and Neurobiology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
- Research Center for Child Mental Development, Kanazawa University, Kanazawa, Japan
| | - Yuko Yoshimura
- Research Center for Child Mental Development, Kanazawa University, Kanazawa, Japan
- Faculty of Education, Institute of Human and Social Sciences, Kanazawa University, Kanazawa, Japan
| | - Chiaki Hasegawa
- Research Center for Child Mental Development, Kanazawa University, Kanazawa, Japan
| | - Kyung-Min An
- School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Sanae Tanaka
- Research Center for Child Mental Development, Kanazawa University, Kanazawa, Japan
| | - Ken Yaoi
- Research Center for Child Mental Development, Kanazawa University, Kanazawa, Japan
| | - Nobushige Naitou
- Department of Psychiatry and Neurobiology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Mitsuru Kikuchi
- Department of Psychiatry and Neurobiology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
- Research Center for Child Mental Development, Kanazawa University, Kanazawa, Japan
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Smith JV, Menezes M, Brunt S, Pappagianopoulos J, Sadikova E, O Mazurek M. Understanding autism diagnosis in primary care: Rates of diagnosis from 2004 to 2019 and child age at diagnosis. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024:13623613241236112. [PMID: 38456360 DOI: 10.1177/13623613241236112] [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: 03/09/2024]
Abstract
LAY ABSTRACT The current demand for autism diagnostic services exceeds the ability of the workforce to assess and diagnose children in a timely manner. One solution may be to equip primary care providers (PCPs) with the tools and expertise needed to diagnose autism within their practice. PCPs are often trusted professionals who have many touchpoints with children during early development, in which they can identify early signs of autism. Recent initiatives have focused on bolstering PCPs' diagnostic capabilities; however, no studies have examined how the rates of autism diagnosis in primary care have changed over time. We aimed to evaluate whether autism diagnosis in primary care has changed over time and how diagnosis in primary care relates to a child's age at the time of diagnosis. We found that the likelihood of a child being diagnosed by a PCP decreased by about 2% with every passing year from 2004 to 2019 when accounting for demographic characteristics. In our sample, PCPs diagnosed children approximately 1 year earlier than non-PCPs (e.g., psychologists and psychiatrists). Further research is needed to understand why the proportion of children diagnosed by PCPs decreases over time. However, this decrease suggests more work is needed to get capacity-building initiatives into community primary care practice. Though we must continue to find effective ways to build community PCPs' ability to diagnose autism, the present findings support the crucial role PCPs can play in early autism diagnosis.
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Affiliation(s)
- Jessica V Smith
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Michelle Menezes
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Sophie Brunt
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Jessica Pappagianopoulos
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Eleonora Sadikova
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
| | - Micah O Mazurek
- Department of Human Services, School of Education and Human Development, University of Virginia, USA
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Gore K, Gilbert M, Hawke M, Barbaro J. Investigating autism knowledge, self-efficacy, and confidence following maternal and child health nurse training for the early identification of autism. Front Neurol 2024; 14:1201292. [PMID: 38264089 PMCID: PMC10803615 DOI: 10.3389/fneur.2023.1201292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/17/2023] [Indexed: 01/25/2024] Open
Abstract
Introduction Early identification of children with a high likelihood of autism can lead to referral for diagnostic services and access to early supports, resulting in improved outcomes for children and families. Maternal and Child Health Nurses (MCHNs) in Victoria, Australia, are well-placed to monitor infants and toddlers for signs of autism, given children and caregivers attend free, regular, well-baby consultations from birth through to school age. This study aimed to identify the impact of personal and workplace factors on MCHNs' competencies of autism knowledge, self-efficacy in identifying autistic infants and toddlers, and confidence in speaking to parents/caregivers about autism. Additionally, the study sought to identify which personal and workplace factors might predict increased competency in these areas. Methods After identifying training needs and current competency levels via a training needs analysis (TNA), 1,428 MCHNs received training on the early signs of autism and in the use of the Social Attention and Communication Surveillance-Revised (SACS-R) tool for early autism identification; the training program was known as Monitoring of Social Attention, Interaction, and Communication (MoSAIC). Results Previous MCHN autism training and knowledge of autism community resources significantly contributed to increased MCHN self-efficacy in identifying autistic infants and toddlers, while knowledge of community resources was the best predictor of confidence in speaking with parents/caregivers about autism. Perceived self-efficacy and confidence in speaking with parents/caregivers about autism significantly increased following the MoSAIC autism training. Discussion Targeted autism training for primary health practitioners is an important first step for early autism identification and initiating conversations with parents/caregivers.
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Affiliation(s)
- Katherine Gore
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
| | | | | | - Josephine Barbaro
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
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Curran C, Roberts R, Gannoni A, Jeyaseelan D. Training and Educational Pathways for Clinicians (Post-graduation) for the Assessment and Diagnosis of Autism Spectrum Disorders: A Scoping Review. J Autism Dev Disord 2024:10.1007/s10803-023-06202-4. [PMID: 38177895 DOI: 10.1007/s10803-023-06202-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/06/2024]
Abstract
This review aimed to identify the post-graduation training pathways available for both clinicians and trainers in the assessment and diagnosis of Autism Spectrum Disorder (ASD). The study was guided by two research questions: What is known about ASD-specific educational, training, or other pathways available to support clinicians of any discipline, post-graduation, to meet the required expertise relevant to assessments of ASD concerns? What is known about the educational pathways available to clinicians seeking to provide training to other clinicians, post-graduation, in the assessment of ASD concerns? A scoping review was undertaken with searches completed across five databases (PubMed, PsycINFO, PsycEXTRA, ERIC and CINAHL). A Google search strategy was also executed using the "advanced" search function. Eligible records were literature, written in English, that examined post-graduation training and/ or education of clinicians to assess and/ or diagnose ASD. Fourteen relevant records were identified. Post-graduate training has the potential to enhance clinician confidence and service provision in ASD assessment and diagnosis. System-wide training approaches show promise in building large-scale, diagnostic capacity and the use of tele-mentoring offers a cost-effective, convenient mode of training delivery. A lack of evidence to support ASD diagnostic training pathways was found and may pose a challenge for clinicians and service users. The limited evidence found suggests that high quality research will be fundamental in determining how to build clinician capacity in ASD assessment and diagnosis and to ascertain whether training pathways are a necessary component.
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Affiliation(s)
- Christine Curran
- School of Psychology, University of Adelaide, Adelaide, SA, Australia
| | - Rachel Roberts
- School of Psychology, University of Adelaide, Adelaide, SA, Australia.
| | - Anne Gannoni
- Child and Adolescent Mental Health Service, Women's and Children's Health Network, North Adelaide, SA, Australia
| | - Deepa Jeyaseelan
- Child Development Unit, Women's and Children's Health Network, North Adelaide, SA, Australia
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Nasir AK, Strong-Bak W, Bernard M. Diagnostic Evaluation of Autism Spectrum Disorder in Pediatric Primary Care. J Prim Care Community Health 2024; 15:21501319241247997. [PMID: 38650542 PMCID: PMC11036916 DOI: 10.1177/21501319241247997] [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: 03/05/2024] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with autism spectrum disorder (ASD) continue to experience significant delays in diagnosis and interventions. One of the main factors contributing to this delay is a shortage of developmental-behavioral specialists. Diagnostic evaluation of ASD by primary care pediatricians (PCPs) has been shown to be reliable and to decrease the interval from first concern to diagnosis. In this paper, we present the results of a primary care ASD diagnosis program in which the PCP serves as the primary diagnostician and leverages the infrastructure of the primary care medical home to support the child and family during the pre- and post-diagnostic periods, along with data on parental satisfaction with this model. METHODS Retrospective data from a cohort of patients evaluated through this program were analyzed to determine the mean age at diagnosis and interval from referral for evaluation to diagnosis. We used survey methodology to obtain data from parents regarding their satisfaction with the process. RESULTS Data from 8 of 20 children evaluated from April 2021 through May 2022 showed a median age of diagnosis of 34.5 months compared to the national average of 49 months. Mean interval from referral for evaluation to diagnosis was 3.5 months. Parental survey responses indicated high satisfaction. CONCLUSIONS This model was successful in shortening the interval from referral to diagnosis resulting in significant decrease of age at diagnosis compared with the national average. Widespread implementation could improve access to timely diagnostic services and improve outcomes for children with ASD.
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Affiliation(s)
- Arwa K. Nasir
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Marie Bernard
- University of Nebraska Medical Center, Omaha, NE, USA
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Penner M, Lai MC. Enhancing access to autism diagnostic services for children in the community. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2023; 27:2201-2204. [PMID: 37736667 DOI: 10.1177/13623613231201212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
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12
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Honaker MG, Weitlauf AS, Swanson AR, Hooper M, Sarkar N, Wade J, Warren ZE. Paisley: Preliminary validation of a novel app-based e-Screener for ASD in children 18-36 months. Autism Res 2023; 16:1963-1975. [PMID: 37602567 PMCID: PMC10857772 DOI: 10.1002/aur.2997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023]
Abstract
The purpose of this study was to assess the validity of an autism e-screener, Paisley, when utilized in a clinical research setting via a tablet application. The Paisley application used a series of play-based activities, all of which incorporated varying aspects of the ASD-PEDS. Participants included children (18-36 months; n = 198) referred for evaluation of autism spectrum disorder (ASD) and community providers (n = 66) with differing levels of familiarity with ASD. Community providers administered the Paisley application to children who then completed a comprehensive psychological evaluation. Based on comprehensive evaluation, 75% of children met diagnostic criteria for ASD. Paisley scores were significantly higher for children diagnosed with ASD (15.06) versus those not diagnosed (9.34). The newly determined cutoff ASD-PEDS cutoff score of 13 had significantly higher specificity and positive predictive value than the originally proposed cutoff of 11. Results support the use of Paisley by community providers to identify autism risk in toddlers. Limitations and strengths of the work, as well as opportunities for future clinical validation, are described.
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Affiliation(s)
- Makayla G Honaker
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Kennedy Center, Treatment and Research Institute for Autism Spectrum Disorders (TRIAD), Nashville, Tennessee, USA
| | - Amy S Weitlauf
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Kennedy Center, Treatment and Research Institute for Autism Spectrum Disorders (TRIAD), Nashville, Tennessee, USA
| | - Amy R Swanson
- Vanderbilt Kennedy Center, Treatment and Research Institute for Autism Spectrum Disorders (TRIAD), Nashville, Tennessee, USA
- Adaptive Technology Consulting, Nashville, Tennessee, USA
| | - Madison Hooper
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nilanjan Sarkar
- Adaptive Technology Consulting, Nashville, Tennessee, USA
- Department of Mechanical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Joshua Wade
- Adaptive Technology Consulting, Nashville, Tennessee, USA
| | - Zachary E Warren
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Special Education, Vanderbilt University, Nashville, Tennessee, USA
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Johnson NL, Fial A, Van Hecke AV, Whitmore K, Meyer K, Pena S, Carlson M, Koth KA. A Scoping Review of Diagnosis of Autism Spectrum Disorder in Primary Care. J Pediatr Health Care 2023; 37:519-527. [PMID: 37178094 DOI: 10.1016/j.pedhc.2023.04.003] [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] [Received: 03/11/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION This scoping review was performed to collect, examine, and present literature on interventions promoting the diagnosis of Autism Spectrum Disorder (ASD) in U.S. primary health care settings. METHOD The literature searched was from 2011-2022, in the English language, in PubMed, CINAHL, Psych INFO, Cochrane, and Web of Science, for persons with autism or ASD aged ≤ 18 years. RESULTS Six studies met the search criteria, including a quality improvement project, a feasibility study, a pilot study, and three primary care provider (PCP) intervention trials. Measured outcomes included: accuracy of diagnosis (n = 4), practice change maintenance (n = 3), time to diagnosis (n = 2), specialty clinic appointment wait time (n = 1), PCP comfort making ASD diagnosis (n = 1), and increased ASD diagnosis (n = 1). DISCUSSION Results inform future implementation of PCP ASD diagnosis for the most obvious cases of ASD and research evaluating PCP training, using longitudinal measures of PCP knowledge of ASD and intention to diagnose.
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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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O'Hara PT, Talero Cabrejo P, Earland TV. Early detection of neurodevelopmental disorders in paediatric primary care: A scoping review. Fam Pract 2023:cmad072. [PMID: 37491000 DOI: 10.1093/fampra/cmad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Earlier detection of children at risk for neurodevelopmental disorders is critical and has longstanding repercussions if not addressed early enough. OBJECTIVES To explore the supporting or facilitating characteristics of paediatric primary care models of care for early detection in infants and toddlers at risk for neurodevelopmental disorders, identify practitioners involved, and describe how they align with occupational therapy's scope of practice. METHODS A scoping review following the Joanna Briggs Institute framework was used. PubMed Central, Cumulative Index to Nursing & Allied Health Literature, and Scopus databases were searched. The search was conducted between January and February 2022. Inclusion criteria were: children aged 0-3 years old; neurodevelopmental disorders including cerebral palsy (CP) and autism spectrum disorder (ASD); models of care used in the paediatric primary care setting and addressing concepts of timing and plasticity; peer-reviewed literature written in English; published between 2010 and 2022. Study protocol registered at https://doi.org/10.17605/OSF.IO/MD4K5. RESULTS We identified 1,434 publications, yielding 22 studies that met inclusion criteria. Models of care characteristics included the use of technology, education to parents and staff, funding to utilize innovative models of care, assessment variability, organizational management changes, increased visit length, earlier timeline for neurodevelopmental screening, and collaboration with current office staff or nonphysician practitioners. The top 4 providers were paediatricians, general or family practitioners, nurse/nurse practitioners, and office staff. All studies aligned with occupational therapy health promotion scope of practice and intervention approach yet did not include occupational therapy within the paediatric primary care setting. CONCLUSIONS No studies included occupational therapy as a healthcare provider that could be used within the paediatric primary care setting. However, all studies demonstrated models of care facilitating characteristics aligning with occupational therapy practice. Models of care facilitating characteristics identified interdisciplinary staff as a major contributor, which can include occupational therapy, to improve early detection within paediatric primary care.
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Affiliation(s)
- Paulette T O'Hara
- Department of Public Health, California Children's Services, Los Angeles, CA, United States
- Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, PA, United States
| | - Pamela Talero Cabrejo
- Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, PA, United States
| | - Tracey V Earland
- Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, PA, United States
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Male I, Farr W, Bremner S, Gage H, Williams P, Gowling E, Honey E, Gain A, Parr J. An observational study of individual child journeys through autism diagnostic pathways, and associated costs, in the UK National Health Service. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1119288. [PMID: 37350848 PMCID: PMC10283036 DOI: 10.3389/fresc.2023.1119288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/02/2023] [Indexed: 06/24/2023]
Abstract
Background Demand for diagnostic assessment in children with possible autism has recently increased significantly. Services are under pressure to deliver timely and high-quality diagnosis, following National Institute and Care Excellence multidisciplinary assessment guidelines. This UK National Health Service study aimed to answer: how many hours of health professional time are required to deliver autism diagnostic assessment, and how much does this cost?. Method Case notes of 20 children (1-16 yrs.) from 27 NHS trusts, assessed through an autism diagnostic pathway in the previous year, were examined retrospectively. Data included: hours of professional time, diagnostic outcome. Assessment costs calculated using standardised NHS tariffs. Results 488 children (aged 21-195 months, mean 82.9 months, SD 39.36) from 22 Child Development Services (CDS), four Child and Adolescent Mental Health Services (CAMHS) and one tertiary centre; 87% were either under 5 (36%) or 5 to 11 years (51%). Children seen by CDS were younger than CAMHS (mean (SD) 6.10 (2.72) vs. 10.39 (2.97) years, p < 0.001). Mean days to diagnosis were 375 (SD 235), with large variation (range 41-1553 days). Mean hours of professional time per child was 11.50 (SD 7.03) and varied substantially between services and individuals. Mean cost of assessment was £846.00 (SD 536.31). 339 (70.0%) children received autism diagnosis with or without comorbidity; 54 (11%) received no neurodevelopmental diagnosis; 91 (19%) received alternative neurodevelopmental diagnoses. Children with one or more coexisting conditions took longer to diagnose, and assessment was more costly, on average 117 days longer, costing £180 more than a child with no neurodevelopmental diagnosis. Age did not predict days to diagnosis or assessment costs. Conclusion Typical assessment took 11 h of professional time and over 12-months to complete, costing GB£850 per child. Variation between centres and children reflect differences in practice and complexity of diagnostic presentation. These results give information to those delivering/planning autism assessments using multi-disciplinary team approach, in publicly funded health systems. Planning of future diagnostic services needs to consider growing demand, the need for streamlining, enabling context appropriate services, and child/family complexity.
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Affiliation(s)
- Ian Male
- Research Department, Sussex Community NHS Foundation Trust, West Sussex, United Kingdom
- Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - William Farr
- Research Department, Sussex Community NHS Foundation Trust, West Sussex, United Kingdom
- Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
- Faculty of Education, University of Cambridge, Cambridge, United Kingdom
| | - Stephen Bremner
- Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Heather Gage
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Peter Williams
- School of Mathematics, University of Surrey, Guildford, United Kingdom
| | - Emma Gowling
- Geriatrics, Queen Alexandra Hospital, Cosham, United Kingdom
| | - Emma Honey
- Paediatrics, Northumberland Tyne and Wear National Health Service, Newcastle Upon Tyne, United Kingdom
| | - Aaron Gain
- Public Health, University of Brighton, Brighton, UK
| | - Jeremy Parr
- Paediatrics, Northumberland Tyne and Wear National Health Service, Newcastle Upon Tyne, United Kingdom
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
- Faculty of Medical Sciences, Great North Children's Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
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Penner M, Senman L, Andoni L, Dupuis A, Anagnostou E, Kao S, Solish A, Shouldice M, Ferguson G, Brian J. Concordance of Diagnosis of Autism Spectrum Disorder Made by Pediatricians vs a Multidisciplinary Specialist Team. JAMA Netw Open 2023; 6:e2252879. [PMID: 36696109 DOI: 10.1001/jamanetworkopen.2022.52879] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
IMPORTANCE Wait times for autism spectrum disorder (ASD) diagnosis are lengthy because of inadequate supply of specialist teams. General pediatricians may be able to diagnose some cases of ASD, thereby reducing wait times. OBJECTIVE To determine the accuracy of ASD diagnostic assessments conducted by general pediatricians compared with a multidisciplinary team (MDT). DESIGN, SETTING, AND PARTICIPANTS This prospective diagnostic study was conducted in and a specialist assessment center in Toronto, Ontario, Canada, and Ontario general pediatrician practices from June 2016 to March 2020. Children were younger than 5.5 years, referred with a developmental concern, and without an existing ASD diagnosis. Data analysis was performed from October 2021 to February 2022. EXPOSURES The pediatrician and MDT each conducted blinded assessments and recorded a decision as to whether the child had ASD. MAIN OUTCOMES AND MEASURES Main outcomes included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A logistic regression was performed to identify factors associated with accurate pediatrician assessment for children with or without an ASD diagnosis. RESULTS Seventeen pediatricians (12 women [71%]) participated in the study and referred 106 children (79 boys [75%]; mean [SD] age, 41.9 [13.3] months). Sixty participants (57%) were from minoritized racial and ethnic groups (eg, Black, Asian, Hispanic, Middle Eastern, and multiracial). Seventy-two participants (68%) received a diagnosis of ASD by the MDT. Sensitivity and specificity of the pediatrician assessments compared with MDT were 0.75 (95% CI, 0.67-0.83) and 0.79 (95% CI, 0.62-0.91), respectively. The PPV of the pediatrician assessments was 0.89 (95% CI, 0.80-0.94) (ie, 89% agreement with the MDT), and NPV was 0.60 (95% CI, 0.49-0.70) (ie, 60% agreement with the MDT). Higher pediatrician certainty (odds ratio [OR], 3.33; 95% CI, 1.71-7.34; P = .001) was associated with increased diagnostic accuracy for children with ASD. Lower accuracy was seen for children with higher Visual Reception subscale developmental skills (OR, 0.93; 95% CI, 0.89-0.97; P = .001), speaking abilities (OR, 0.17; 95% CI, 0.03-0.67; P = .03), and White race (OR, 0.32; 95% CI, 0.10-0.97; P = .04). Age, gender, and Autism Diagnostic Observation Schedule, 2nd Edition composite scores were not significantly associated with the accuracy of assessments. All 7 children with a sibling with ASD received an accurate diagnosis; otherwise, no significant factors were identified for accuracy in children without ASD. CONCLUSIONS AND RELEVANCE This study of concordance of autism assessment between pediatricians and an expert MDT in young children found high accuracy when general pediatricians felt confident and lower accuracy when ruling out ASD. These findings suggest that children with co-occurring delays may be potential candidates for community assessment.
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Affiliation(s)
- Melanie Penner
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lili Senman
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Lana Andoni
- Department of Psychology, University of Massachusetts, Boston
| | - Annie Dupuis
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Evdokia Anagnostou
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Kao
- Pediatricians Alliance of Ontario, Toronto, Ontario, Canada
| | - Abbie Solish
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Michelle Shouldice
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Genevieve Ferguson
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Jessica Brian
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Williams LN, Wieckowski AT, Dieckhaus MFS, Dai YG, Zhang F, Dumont-Mathieu T, Barton M, Fein D, Robins DL. Primary Care Clinician and Child Characteristics Impacting Autism Surveillance. Brain Sci 2022; 13:brainsci13010018. [PMID: 36672000 PMCID: PMC9855901 DOI: 10.3390/brainsci13010018] [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] [Received: 11/12/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Early detection of autism provides access to early intervention and subsequently fewer lifelong challenges. However, disparities in screening have been associated with socioeconomic status (SES) and race, and disparities in surveillance have been associated with clinician knowledge and beliefs about autism identification. The present study examines associations between demographic variables and clinician beliefs, and agreement between screening results and clinician surveillance. Surveillance included activities used by the primary care clinicians (PCCs) to assess risk for autism. PCCs reported their beliefs about autism screening and identification, their sex, race, years in practice, and racial distribution of their patient population. Children's demographic information was also collected. PCCs identified children as having, or not having, an increased likelihood of autism, and parents of children completed an autism screener. Agreement between screening and surveillance results were examined across PCC, practice, and child demographics. Higher confidence in autism knowledge and screening resources, female PCC sex, and majority White practice patient demographics all predicted agreement between screening and surveillance. Female child sex and higher maternal education also predicted agreement between screening and surveillance. These findings highlight the importance of PCC screening beliefs and child and PCC demographics on the autism identification process.
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Affiliation(s)
- Lashae N. Williams
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA 19104, USA
- Correspondence:
| | | | - Mary F. S. Dieckhaus
- Department of Psychological Sciences, University of Connecticut, Storrs, CT 06269, USA
| | - Yael G. Dai
- Department of Psychological Sciences, University of Connecticut, Storrs, CT 06269, USA
| | - Fengqing Zhang
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, PA 19104, USA
| | - Thyde Dumont-Mathieu
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT 06032, USA
| | - Marianne Barton
- Department of Psychological Sciences, University of Connecticut, Storrs, CT 06269, USA
| | - Deborah Fein
- Department of Psychological Sciences, University of Connecticut, Storrs, CT 06269, USA
| | - Diana L. Robins
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA 19104, USA
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Attar SM, Ibanez LV, Stone WL. Separate scoring algorithms for specific identification priorities optimize the screening properties of the Screening Tool for Autism in Toddlers (STAT). Autism Res 2022; 15:2069-2080. [PMID: 36073529 PMCID: PMC9637685 DOI: 10.1002/aur.2799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
The Screening Tool for Autism in Toddlers (STAT) is a validated stage-2 autism spectrum disorder (ASD) screening measure that takes 20 minutes to administer and comprises 12 play-based items that are scored according to specific criteria. This study examines an expanded version (STAT-E) that includes the examiner's subjective ratings of children's social engagement (SE) and atypical behaviors (AB) in the scoring algorithm. The sample comprised 238 children who were 24-35 months old. The STAT-E assessors had limited ASD experience to mimic its use by community-based non-specialists, and were trained using a scalable web-based platform. A diagnostic evaluation was completed by clinical experts who were blind to the STAT-E results. Logistic regression, ROC curves, and classification matrices and metrics were used to determine the screening properties of STAT-E when scored using the original STAT scoring algorithm versus a new algorithm that included the SE and AB ratings. Inclusion of the SE and AB ratings improved positive risk classification appreciably, while the specificity declined. These results suggest that the STAT-E using the original STAT scoring algorithm optimizes specificity, while the STAT-E scoring algorithm with the two new ratings optimizes the positive risk classification. Using multiple scoring algorithms on the STAT may provide improved screening accuracy for diverse contexts, and a scalable web-based tutorial may be a pathway for increasing the number of community providers who can administer the STAT and contribute toward increased rates of autism screening.
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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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Clarke L, Fung LK. The impact of autism-related training programs on physician knowledge, self-efficacy, and practice behavior: A systematic review. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2022; 26:1626-1640. [PMID: 35698749 DOI: 10.1177/13623613221102016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
LAY ABSTRACT Autism spectrum disorder is estimated to impact 1.5 million children and almost 5.5 million adults. However, most physicians do not receive training on how to provide care to this increasingly large group of people. After performing a systematic review of the literature and screening over 4,500 unique articles focused on the effectiveness of autism-specific training programs designed for physicians and physician trainees, we determined that 17 studies met the pre-determined criteria for inclusion in this systematic review. The results reported by these studies suggest that by completing specialized training programs related to autism, physicians were more knowledgeable on topics related to the condition, more confident in their ability to provide care to autistic individuals, and more likely to screen their patients for autism spectrum disorder. However, further studies with higher quality data are needed to validate these findings and provide additional insight on the ability of these programs to improve physician behavior and patient outcomes. We are therefore advocating that medical educators develop and evaluate specialized autism training programs with an increased focus on improving physician behavior related to all aspects of providing care to autistic people.
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22
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Do Autism-Specific and General Developmental Screens Have Complementary Clinical Value? J Autism Dev Disord 2022:10.1007/s10803-022-05541-y. [PMID: 35579791 PMCID: PMC10214166 DOI: 10.1007/s10803-022-05541-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 10/18/2022]
Abstract
Prior studies suggest autism-specific and general developmental screens are complementary for identifying both autism and developmental delay (DD). Parents completed autism and developmental screens before 18-month visits. Children with failed screens for autism (n = 167) and age, gender, and practice-matched children passing screens (n = 241) completed diagnostic evaluations for autism and developmental delay. When referral for autism and/or DD was considered, overall false positives from the autism screens were less frequent than for referral for autism alone. Presence of a failed communication subscale in the developmental screen was a red flag for autism and/or DD. An ordinally-scored autism screen had more favorable characteristics when considering autism and/or DD, yet none of the screens achieved recommended standards at 18 months, reinforcing the need for recurrent screening as autism emerges in early development.
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23
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Das J, Hartman L, King G, Jones-Stokreef N, Moore Hepburn C, Penner M. Perspectives of Canadian Rural Consultant Pediatricians on Diagnosing Autism Spectrum Disorder: A Qualitative Study. J Dev Behav Pediatr 2022; 43:149-158. [PMID: 34510107 PMCID: PMC8953388 DOI: 10.1097/dbp.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 07/23/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Consultant pediatricians represent a potential resource for increasing autism spectrum disorder (ASD) diagnostic capacity; however, little is known about how they perceive their roles in ASD diagnosis. OBJECTIVE The objective of this study was to examine the perspectives of rural consultant pediatricians regarding their perceived roles, facilitators, and barriers in ASD diagnosis. METHODS We performed a qualitative study using thematic analysis. Consultant pediatricians from 3 small-sized and medium-sized Ontario communities were recruited. Semistructured interviews were conducted, transcribed, coded, and analyzed. RESULTS Fourteen pediatricians participated in this study. Participants all considered ASD diagnosis to be in their scope of practice. The major theme identified was the process of diagnosing ASD, which occurred in 3 stages: preassessment (gathering information before the first clinic visit), diagnosis, and service access. All these stages are influenced by ecological factors consisting of characteristics of the child, family, individual physician, pediatric group practice, and the broader system of ASD care. CONCLUSION Consultant pediatricians practicing in nonurban Ontario communities see ASD diagnosis as part of their scope of practice and collaboratively work within groups to address the needs of their communities. Strategies aimed at increasing diagnostic capacity should target salaried group practices and improve the efficiency of assessments through preclinic information gathering.
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Affiliation(s)
- Jennifer Das
- Division of Developmental Pediatrics, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Laura Hartman
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Gillian King
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | | | | | - Melanie Penner
- Division of Developmental Pediatrics, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
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Mire SS, Keller‐Margulis MA, Izuno‐Garcia AK, Jellinek ER, Loría Garro ES. Evaluating the feasibility of remotely administered curriculum‐based measurement for students with autism: A pilot study. PSYCHOLOGY IN THE SCHOOLS 2022. [DOI: 10.1002/pits.22668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sarah S. Mire
- Department of Psychological, Health, and Learning Sciences University of Houston Houston Texas USA
| | | | - Amy K. Izuno‐Garcia
- Department of Psychological, Health, and Learning Sciences University of Houston Houston Texas USA
| | - Emily R. Jellinek
- Department of Psychological, Health, and Learning Sciences University of Houston Houston Texas USA
| | - Elías S. Loría Garro
- Department of Psychological, Health, and Learning Sciences University of Houston Houston Texas USA
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Sturner R, Howard B, Bergmann P, Attar S, Stewart-Artz L, Bet K, Allison C, Baron-Cohen S. Autism screening at 18 months of age: a comparison of the Q-CHAT-10 and M-CHAT screeners. Mol Autism 2022; 13:2. [PMID: 34980240 PMCID: PMC8722322 DOI: 10.1186/s13229-021-00480-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 12/07/2021] [Indexed: 01/04/2023] Open
Abstract
Background Autism screening is recommended at 18- and 24-month pediatric well visits. The Modified Checklist for Autism in Toddlers—Revised (M-CHAT-R) authors recommend a follow-up interview (M-CHAT-R/F) when positive. M-CHAT-R/F may be less accurate for 18-month-olds than 24-month-olds and accuracy for identification prior to two years is not known in samples that include children screening negative. Since autism symptoms may emerge gradually, ordinally scoring items based on the full range of response options, such as in the 10-item version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT-10), might better capture autism signs than the dichotomous (i.e., yes/no) items in M-CHAT-R or the pass/fail scoring of Q-CHAT-10 items. The aims of this study were to determine and compare the accuracy of the M-CHAT-R/F and the Q-CHAT-10 and to describe the accuracy of the ordinally scored Q-CHAT-10 (Q-CHAT-10-O) for predicting autism in a sample of children who were screened at 18 months.
Methods This is a community pediatrics validation study with screen positive (n = 167) and age- and practice-matched screen negative children (n = 241) recruited for diagnostic evaluations completed prior to 2 years old. Clinical diagnosis of autism was based on results of in-person diagnostic autism evaluations by research reliable testers blind to screening results and using the Autism Diagnostic Observation Schedule—Second Edition (ADOS-2) Toddler Module and Mullen Scales of Early Learning (MSEL) per standard guidelines.
Results While the M-CHAT-R/F had higher specificity and PPV compared to M-CHAT-R, Q-CHAT-10-O showed higher sensitivity than M-CHAT-R/F and Q-CHAT-10. Limitations Many parents declined participation and the sample is over-represented by higher educated parents. Results cannot be extended to older ages. Conclusions Limitations of the currently recommended two-stage M-CHAT-R/F at the 18-month visit include low sensitivity with minimal balancing benefit of improved PPV from the follow-up interview. Ordinal, rather than dichotomous, scoring of autism screening items appears to be beneficial at this age. The Q-CHAT-10-O with ordinal scoring shows advantages to M-CHAT-R/F with half the number of items, no requirement for a follow-up interview, and improved sensitivity. Yet, Q-CHAT-10-O sensitivity is less than M-CHAT-R (without follow-up) and specificity is less than the two-stage procedure. Such limitations are consistent with recognition that screening needs to recur beyond this age. Supplementary Information The online version contains supplementary material available at 10.1186/s13229-021-00480-4.
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Affiliation(s)
- Raymond Sturner
- Pediatrics, Johns Hopkins School of Medicine, Baltimore, USA. .,Center for Promotion of Child Development Through Primary Care, Baltimore, MD, USA.
| | - Barbara Howard
- Pediatrics, Johns Hopkins School of Medicine, Baltimore, USA.,CHADIS, Inc., 6017 Altamont Place, Baltimore, MD, USA
| | - Paul Bergmann
- CHADIS, Inc., 6017 Altamont Place, Baltimore, MD, USA.,Foresight Logic, Inc., St. Paul, MN, USA
| | - Shana Attar
- CHADIS, Inc., 6017 Altamont Place, Baltimore, MD, USA.,University of Washington, Seattle, WA, USA
| | - Lydia Stewart-Artz
- Center for Promotion of Child Development Through Primary Care, Baltimore, MD, USA
| | - Kerry Bet
- Center for Promotion of Child Development Through Primary Care, Baltimore, MD, USA.,CHADIS, Inc., 6017 Altamont Place, Baltimore, MD, USA
| | - Carrie Allison
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Simon Baron-Cohen
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
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Guan X, Zwaigenbaum L, Sonnenberg LK. Building Capacity for Community Pediatric Autism Diagnosis: A Systemic Review of Physician Training Programs. J Dev Behav Pediatr 2022; 43:44-54. [PMID: 34907998 PMCID: PMC8687619 DOI: 10.1097/dbp.0000000000001042] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/12/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Training primary care providers to provide diagnostic assessments for autism spectrum disorder (ASD) decreases wait times and improves diagnostic access. Outcomes related to the quality of these assessments and the impacts on system capacity have not been systematically examined. This systematic review identifies and summarizes published studies that included ASD diagnostic training for primary care providers (PCPs) and aims to guide future training and evaluation methods. METHODS Systematic searches of electronic databases, reference lists, and journals identified 6 studies that met 3 inclusion criteria: training for PCPs, community setting, and training outcome(s) reported. These studies were critically reviewed to characterize (1) study design, (2) training model, and (3) outcomes. RESULTS All studies were either pre-post design or nonrandomized trials with a relatively small number of participants. There was considerable heterogeneity among studies regarding the training provided and the program evaluation process. The most evaluated outcomes were access to autism diagnosis and accuracy of diagnosis. CONCLUSION Training PCPs to make ASD diagnoses can yield high diagnostic agreement with specialty teams' assessments and reduce diagnostic wait times. Current data are limited by small sample size, poor to fair quality study methodology, and heterogenous study designs and outcome evaluations. Evidence is insufficient to draw conclusions about the overall effects of training PCPs for ASD diagnostic assessments. Since further research is still needed, this review highlights which outcomes are relevant to consider when evaluating the quality of ASD assessments across the continuum of approaches.
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Affiliation(s)
- Xiaoning Guan
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada;
| | | | - Lyn K. Sonnenberg
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada;
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Abrahamson V, Zhang W, Wilson PM, Farr W, Reddy V, Parr J, Peckham A, Male I. Realist evaluation of Autism ServiCe Delivery (RE-ASCeD): which diagnostic pathways work best, for whom and in what context? Findings from a rapid realist review. BMJ Open 2021; 11:e051241. [PMID: 34907053 PMCID: PMC8672008 DOI: 10.1136/bmjopen-2021-051241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 10/20/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Waiting times in the UK for an autism diagnostic assessment have increased rapidly in the last 5 years. This review explored research (including 'grey' literature) to uncover the current evidence base about autism diagnostic pathways and what works best, for whom and in what circumstances, to deliver high quality and timely diagnosis. DESIGN We performed a Rapid Realist Review consistent with recognised standards for realist syntheses. We collected 129 grey literature and policy/guidelines and 220 articles from seven databases (January 2011-December 2019). We developed programme theories of how, why and in what contexts an intervention worked, based on cross comparison and synthesis of evidence. The focus was on identifying factors that contributed to a clearly defined intervention (the diagnostic pathway), associated with specific outcomes (high quality and timely), within specific parameters (Autism diagnostic services in Paediatric and Child & Adolescent Mental Health services in the UK). Our Expert Stakeholder Group, including representatives from local parent forums, national advocacy groups and clinicians, was integral to the process. RESULTS Based on 45 relevant articles, we identified 7 programme theories that were integral to the process of diagnostic service delivery. Four were related to the clinical pathway: initial recognition of possible autism; referral and triaging; diagnostic model; and providing feedback to parents. Three programme theories were pertinent to all stages of the referral and diagnostic process: working in partnership with families; interagency working; and training, service evaluation and development. CONCLUSIONS This theory informed review of childhood autism diagnostic pathways identified important aspects that may contribute to efficient, high quality and family-friendly service delivery. The programme theories will be further tested through a national survey of current practice and in-depth longitudinal case studies of exemplar services. TRIAL REGISTRATION NUMBER NCT04422483.
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Affiliation(s)
| | - Wenjing Zhang
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Patricia M Wilson
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - William Farr
- Sussex Community NHS Foundation Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Venkat Reddy
- Peterborough Child Development Centre, Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn, Cambridgeshire, UK
| | - Jeremy Parr
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
- Cumbria, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Anna Peckham
- Centre for Health Service Studies, University of Kent, Canterbury, UK
| | - Ian Male
- Sussex Community NHS Foundation Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
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Wieckowski AT, Thomas RP, Chen CMA, Zitter A, Fein DA, Barton ML, Adamson LB, Robins DL. Effect of Brief Training to Identify Autism Spectrum Disorder During Toddler Well-Child Care Visits. J Dev Behav Pediatr 2021; 42:666-671. [PMID: 34618724 PMCID: PMC8497937 DOI: 10.1097/dbp.0000000000000938] [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: 07/01/2020] [Accepted: 01/01/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the effect of a brief Enhanced training using the information-motivation-behavior (IMB) change model on improving providers' surveillance rates and accuracy of autism spectrum disorder (ASD) detection. METHOD Toddlers (n = 5,672) were screened for ASD during their pediatric well-child visits. Pediatric providers (n = 120) were randomized to receive Enhanced (incorporating components of the IMB model) or Control training. Providers indicated whether they had an ASD concern at each well-child visit. Toddlers who were positive on any screener and/or whose provider indicated ASD concern were invited for a diagnostic evaluation. Differences in provider-indicated ASD concerns before and after training were evaluated using log-linear analyses. RESULTS The Enhanced training did not have a significant effect on provider-endorsed ASD concerns (p = 0.615) or accuracy of endorsing concerns (p = 0.619). Providers in the Control training showed a significant reduction in indicating whether or not they had concerns after the training (from 71.9% to 64.3%), which did not occur in the Enhanced group. The Enhanced training led to more frequent endorsements of language (χ2 = 8.772, p = 0.003) and restricted and repetitive behavior (χ2 = 7.918, p = 0.005) concerns for children seen after training. CONCLUSION Provider training had limited impact on ASD surveillance, indicating the importance of using formal screening instruments that rely on parent report during well-child visits to complement developmental surveillance. Future research should examine whether providers who indicate specific concerns are more likely to accurately refer children for ASD evaluations.
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Affiliation(s)
| | - Rebecca P. Thomas
- Department of Psychological Sciences, University of Connecticut, Storrs, CT
| | - Chi-Ming A. Chen
- Department of Psychological Sciences, University of Connecticut, Storrs, CT
| | - Ashley Zitter
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA
| | - Deborah A. Fein
- Department of Psychological Sciences, University of Connecticut, Storrs, CT
| | - Marianne L. Barton
- Department of Psychological Sciences, University of Connecticut, Storrs, CT
| | | | - Diana L. Robins
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA
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Keehn RM, Tomlin A, Ciccarelli MR. COVID-19 Pandemic Highlights Access Barriers for Children with Autism Spectrum Disorder. J Dev Behav Pediatr 2021; 42:599-601. [PMID: 34191764 PMCID: PMC10712267 DOI: 10.1097/dbp.0000000000000988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/21/2021] [Indexed: 11/27/2022]
Affiliation(s)
| | - Angela Tomlin
- Department of Pediatrics, Indiana University School of Medicine
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Abstract
OBJECTIVE We developed a colocation "Rapid Developmental Evaluation" (RDE) model for Developmental-Behavioral Pediatrics (DBP) to evaluate young children for developmental concerns raised during routine developmental surveillance and screening in a pediatric primary care Federally Qualified Health Center (FQHC). In this low-income patient population, we anticipated that colocation would improve patient access to DBP and decrease time from referral to first developmental evaluation and therapeutic services. METHODS Children were assessed at the FQHC by a DBP pediatrician, who made recommendations for therapeutic services and further diagnostic evaluations. A retrospective chart review over 27 months (N = 151) investigated dates of referral and visit, primary concern, diagnosis, and referral to tertiary DBP center and associated tertiary DBP center dates of service and diagnoses if appropriate. We surveyed primary care clinicians (PCCs) for satisfaction. RESULTS The DBP pediatrician recommended that 51% of children be referred to the tertiary DBP center for further diagnostic evaluation or routine DBP follow-up. Average wait from referral to an RDE visit was 57 days compared with 137.3 days for the tertiary DBP center. Children referred from RDE to the tertiary DBP center completed visits at a higher rate (77%) than those referred from other sites (54%). RDE-recommended therapeutic services were initiated for 73% of children by the tertiary visit. Fidelity of diagnosis between RDE and the tertiary DBP center was high, as was PCC satisfaction. CONCLUSION Colocation of a DBP pediatrician in an FQHC primary care pediatrics program decreased time to first developmental assessment and referral for early intervention services for an at-risk, low-income patient population.
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Zwaigenbaum L, Warren Z. Commentary: Embracing innovation is necessary to improve assessment and care for individuals with ASD: a reflection on Kanne and Bishop (2020). J Child Psychol Psychiatry 2021; 62:143-145. [PMID: 32472952 DOI: 10.1111/jcpp.13271] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/24/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
Abstract
This commentary is offered in response to Kanne and Bishop (2020) who urge caution in adopting new devices and processes for ASD assessment and advocate that that comprehensive, expert-driven, diagnostic models for ASD remain essential to maintain quality standards. While we agree that there is a critical shortage in current care, we propose that developing suites of tools and innovative approaches for screening, risk-classification, formal diagnosis, and rich assessment of abilities and challenges may be of great value to families and necessary to improve current systems of care. As well, the evaluation of 'assessment quality' should take into consideration both content and process, with a focus on achieving meaningful outcomes and optimizing family experience.
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Affiliation(s)
| | - Zachary Warren
- Vanderbilt Kennedy Center, Vanderbilt University, Nashville, TN, USA
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Toward Novel Tools for Autism Identification: Fusing Computational and Clinical Expertise. J Autism Dev Disord 2021; 51:4003-4012. [PMID: 33417138 PMCID: PMC7791904 DOI: 10.1007/s10803-020-04857-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2020] [Indexed: 01/04/2023]
Abstract
Barriers to identifying autism spectrum disorder (ASD) in young children in a timely manner have led to calls for novel screening and assessment strategies. Combining computational methods with clinical expertise presents an opportunity for identifying patterns within large clinical datasets that can inform new assessment paradigms. The present study describes an analytic approach used to identify key features predictive of ASD in young children, drawn from large amounts of data from comprehensive diagnostic evaluations. A team of expert clinicians used these predictive features to design a set of assessment activities allowing for observation of these core behaviors. The resulting brief assessment underlies several novel approaches to the identification of ASD that are the focus of ongoing research.
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Hine JF, Wagner L, Goode R, Rodrigues V, Taylor JL, Weitlauf A, Warren ZE. Enhancing developmental-behavioral pediatric rotations by teaching residents how to evaluate autism in primary care. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2021; 25:1492-1496. [PMID: 33401941 DOI: 10.1177/1362361320984313] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
LAY ABSTRACT Most physician preparation programs do not provide enough practical experiences in autism-related care. This is especially true for how to assess for and diagnose autism. Without this training, many pediatricians are not well prepared to implement appropriate care for children with autism and their families. We designed a curriculum to improve training for medical residents that involved explicit hands-on training in diagnostic identification and care coordination for toddlers at risk for autism. We collected data to assess whether our enhanced curriculum led to increased comfort level across recommended practice behaviors. Almost all the residents were able to complete the training within their rotation and our surveys indicated significant increases in residents feeling more comfortable identifying symptoms of autism, providing feedback about diagnostic decisions, and effectively connecting families with services. A significant majority of residents considered it appropriate or very appropriate for children to receive a diagnosis solely from a primary care provider. Our results suggest feasibility of the enhanced model, and this project reflects the first step in advancing incorporation of autism training into pediatric residency programs.
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Hus Y, Segal O. Challenges Surrounding the Diagnosis of Autism in Children. Neuropsychiatr Dis Treat 2021; 17:3509-3529. [PMID: 34898983 PMCID: PMC8654688 DOI: 10.2147/ndt.s282569] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/10/2021] [Indexed: 12/18/2022] Open
Abstract
This comprehensive thematic review aims to highlight and familiarize readers with the challenges and pitfalls encountered in differential diagnosis of autism spectrum disorders (ASD) in children to facilitate the process of accurate identification by stakeholders. Accordingly, articles that best answer our questions and highlight our concerns were chosen from well-established publishers with prime peer reviewed journals. Included are studies showing alternate views of the issues so as to point readers to other possibilities. ASD, a complex dynamic biological-neurodevelopmental disorder, is underscored by its heterogeneous symptomology, severity, and phenotypes - all characterized by social communication deficits and presence of restricted interests and repetitive behaviours (RRBs), the core symptoms in ASD. Language and intellectual capacities do not form ASD core symptoms although vary considerably. Accurate identification is challenging as ASD is often enmeshed with other neurodevelopmental disorders, and medical comorbidities, a situation now recognized as the rule rather than the exception in child psychiatry and developmental medicine. ASD is a disorder with varying performance and severity of symptoms over time, including unexpected loss of early skills, and lost diagnosis in some children following treatment. The review reiterates the urgency in accurate diagnosis in face of the rapid rise in ASD prevalence globally, and risk-increase in delayed or denied treatment with undesirable life-long consequences for most of the affected children. In addition, a call for change is advised to circumvent the ethical dilemma posed by the present "deficit model" in ASD diagnosis. Here, ASD prevalence is presented first, followed by emphasis on importance of accurate early diagnosis, and challenges in its accomplishment due to flaws in diagnostic instruments and other contributing factors. Next follow the required criteria for accurate identification, and its difficulties attributed to comorbid conditions, gender differences, and socio-economic and cultural influences. The conclusion includes future directions and a take away message.
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Affiliation(s)
- Yvette Hus
- Cyprus University of Technology, Department of Rehabilitation Sciences, Theralab Research Collaborator, Limassol, Cyprus
| | - Osnat Segal
- Tel Aviv University, Sackler Faculty of Medicine, Department of Communication Disorders, Tel-Aviv, Israel
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Abstract
INTRODUCTION While the overall prevalence of autism is 1.7% in the United States of America, research has demonstrated a two- to five-fold increase in CHD. The Cardiac Neurodevelopmental Outcome Collaborative recommends screening for autism from infancy through adolescence. This study investigated the frequency of autism concerns at a single Cardiac Neurodevelopmental Program and examined current clinical practice as a way to improve quality of care. MATERIALS AND METHODS Patients (n = 134; mean age = 9.0 years) included children with high-risk CHD who completed a neurodevelopmental evaluation following a formalised referral to the Cardiac Neurodevelopmental Program between 2018 and 2019. Retrospective chart review included parent report on the Behaviour Assessment System for Children-3 and Adaptive Behaviour Assessment System-3. Descriptive and correlation analyses were completed. RESULTS In this sample, 11.2% presented with autism-related concerns at referral, 2 were diagnosed with autism, 9 were referred to an autism specialist (6 confirmed diagnosis; 3 not completed). Thus, at least 5.9% of the sample were diagnosed with autism following thorough clinical evaluation. Analyses showed atypicality, along with deficient adaptability, leisure, social, and communication skills. Frequency of early intervention, school supports, and relation with comorbidities are reported. DISCUSSION Prior to assessment recommendations by the Cardiac Neurodevelopmental Outcome Collaborative, autism screening may not be completed systematically in clinical care for CHD. The current sample demonstrates a high frequency of autism in the typically referred clinical sample. Commonly used parent-report measures may reveal concerns but will not help diagnosis. Systematic use of an autism screener is essential.
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McNally Keehn R, Ciccarelli M, Szczepaniak D, Tomlin A, Lock T, Swigonski N. A Statewide Tiered System for Screening and Diagnosis of Autism Spectrum Disorder. Pediatrics 2020; 146:peds.2019-3876. [PMID: 32632023 DOI: 10.1542/peds.2019-3876] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2020] [Indexed: 11/24/2022] Open
Abstract
Although autism spectrum disorder (ASD) can be reliably detected in the second year of life, the average age of diagnosis is 4 to 5 years. Limitations in access to timely ASD diagnostic evaluations delay enrollment in interventions known to improve developmental outcomes. As such, developing and testing streamlined methods for ASD diagnosis is a public health and research priority. In this report, we describe the Early Autism Evaluation (EAE) Hub system, a statewide initiative for ASD screening and diagnosis in the primary care setting. Development of the EAE Hub system involved geographically targeted provision of developmental screening technical assistance to primary care, community outreach, and training primary care clinicians in ASD evaluation. At the EAE Hubs, a standard clinical pathway was implemented for evaluation of children, ages 18 to 48 months, at risk for ASD. From 2012 to 2018, 2076 children were evaluated (mean age: 30 months; median evaluation wait time: 62 days), and 33% of children received a diagnosis of ASD. Our findings suggest that developing a tiered system of developmental screening and early ASD evaluation is feasible in a geographic region facing health care access problems. Through targeted delivery of education, outreach, and intensive practice-based training, large numbers of young children at risk for ASD can be identified, referred, and evaluated in the local primary care setting. The EAE Hub model has potential for dissemination to other states facing similar neurodevelopmental health care system burdens. Implementation lessons learned and key system successes, challenges, and future directions are reviewed.
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Affiliation(s)
- Rebecca McNally Keehn
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Mary Ciccarelli
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Dorota Szczepaniak
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Angela Tomlin
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Thomas Lock
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Nancy Swigonski
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana; and.,Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana
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Murray RE, Barton EE. Training Pediatricians to Implement Autism Screening Tools: a Review of the Literature. REVIEW JOURNAL OF AUTISM AND DEVELOPMENTAL DISORDERS 2020. [DOI: 10.1007/s40489-020-00206-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Increasing Access to Autism Spectrum Disorder Diagnostic Consultation in Rural and Underserved Communities: Streamlined Evaluation Within Primary Care. J Dev Behav Pediatr 2020; 41:16-22. [PMID: 31490843 PMCID: PMC6933088 DOI: 10.1097/dbp.0000000000000727] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Preliminary feasibility and clinical utility research has demonstrated that implementation of a streamlined diagnostic model embedded within primary care (PC) clinics promotes early identification of young children with autism spectrum disorder (ASD). Use of this model results in dramatically reduced waits for diagnostic consultation, high levels of family/provider satisfaction, and reductions in referrals to overtaxed tertiary diagnostic centers. The current study extends this work by providing data before/after implementation of a streamlined model across a diverse range of PC clinics that provide health care to rural and underserved communities. METHODS The streamlined assessment involved record/history review, diagnostic interview, standard rating scales, and an interactive screening tool. Eighty children between the ages of 19 and 47 months were seen across 5 different clinics. Data were collected through chart review. RESULTS Implementation of streamlined model resulted in a significant decrease in latency to diagnostic conclusion from a mean of 144.7 to 49.9 days. Children were likely to experience a greater reduction in wait times if they were a PC patient versus a non-PC patient. CONCLUSION Results show significant reduction in wait times for ASD diagnostic decisions across both PC and non-PC patients. By reducing waits and identifying concerns more efficiently, we may increase the ability of families to access early intervention and support services.
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Juárez AP, Weitlauf AS, Nicholson A, Pasternak A, Broderick N, Hine J, Stainbrook JA, Warren Z. Early Identification of ASD Through Telemedicine: Potential Value for Underserved Populations. J Autism Dev Disord 2019. [PMID: 29527626 DOI: 10.1007/s10803-018-3524-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Increasing access to diagnostic services is crucial for identifying ASD in young children. We therefore evaluated a telemedicine assessment procedure. First, we compared telediagnostic accuracy to blinded gold-standard evaluations (n = 20). ASD cases identified via telemedicine were confirmed by in-person evaluation. However, 20% of children diagnosed with ASD in-person were not diagnosed via telemedicine. Second, we evaluated telediagnostic feasibility and acceptability in a rural catchment. Children (n = 45) and caregivers completed the telemedicine procedure and provided feedback. Families indicated high levels of satisfaction. Remote diagnostic clinicians diagnosed 62% of children with ASD, but did not feel capable of ruling-in or out ASD in 13% of cases. Findings support preliminary feasibility, accuracy, and clinical utility of telemedicine-based assessment of ASD for young children.
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Affiliation(s)
- A Pablo Juárez
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Psychiatry & Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy S Weitlauf
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy Nicholson
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna Pasternak
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Neill Broderick
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey Hine
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Alacia Stainbrook
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zachary Warren
- Vanderbilt Kennedy Center/Treatment and Research Institute for Autism Spectrum Disorders, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Psychiatry & Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Special Education, Vanderbilt University, Nashville, TN, USA.
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Embedding Autism Spectrum Disorder Diagnosis Within the Medical Home: Decreasing Wait Times Through Streamlined Assessment. J Autism Dev Disord 2019; 48:2846-2853. [PMID: 29589272 DOI: 10.1007/s10803-018-3548-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Long waits for diagnostic assessment prevent early identification of children suspected of having autism spectrum disorder. We evaluated the benefit of embedded diagnostic consultation within primary care clinics. Using a streamlined diagnostic model, 119 children with concerns for autism spectrum disorder were seen over 14 months. Diagnostic clarity was determined through streamlined assessment for 59% of the children, while others required follow-up. Latency from first concern to diagnosis was 55 days and median age at diagnosis was 32 months: considerably lower than national averages or comparable tertiary clinics. Findings support that embedded processes for effective triage and diagnosis within the medical home is a viable mechanism for efficient access to diagnostic services and assists in bypassing a common barrier to specialized services.
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Williams-Arya P, Anixt J, Kuan L, Johnson H, Kent B, Bing N, Ehrhardt J, Manning-Courtney P. Improving Access to Diagnostic Assessments for Autism Spectrum Disorder Using an Arena Model. J Dev Behav Pediatr 2019; 40:161-169. [PMID: 30907770 DOI: 10.1097/dbp.0000000000000648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To improve access to diagnostic evaluations for children younger than 3 years with concerns for possible autism spectrum disorder. METHODS A multidisciplinary "arena model" for children younger than 3 years was developed, tested, and implemented over an approximately 2-year period. Arena assessment teams comprised a developmental behavioral pediatrician (DBP), psychologist, and speech language pathologist (SLP). Quality improvement methods were used during the design phase, conducting Plan-Do-Study-Act (PDSA) cycles and collecting feedback from key stakeholders, and during implementation, plotting data on run charts to measure outcomes of the time to initial visit and time to diagnosis. RESULTS Over the 9-month implementation period, 6 arena assessment teams were formed to provide 60 evaluation slots per month for children younger than 3 years. The time to first visit was reduced from a median of 122 days to 19 days, and the time to final diagnosis was reduced from 139 days to 14 days, maintaining these outcomes at <35 and <18 days, respectively, over a 2-year period. Total visits required decreased from 4 to 5 visits to just 2 visits, and the average assessment cost was reduced by $992 per patient. Feedback from both providers and families participating in this model was overwhelmingly positive. CONCLUSION Access for young children referred for developmental assessments can be improved through an understanding of supply and demand and the development of creative and flexible care delivery models.
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Affiliation(s)
- Pamela Williams-Arya
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Julia Anixt
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lisa Kuan
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Heather Johnson
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bridget Kent
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nicole Bing
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jennifer Ehrhardt
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Patricia Manning-Courtney
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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Höfer J, Hoffmann F, Kamp-Becker I, Poustka L, Roessner V, Stroth S, Wolff N, Bachmann CJ. Pathways to a diagnosis of autism spectrum disorder in Germany: a survey of parents. Child Adolesc Psychiatry Ment Health 2019; 13:16. [PMID: 30949235 PMCID: PMC6429704 DOI: 10.1186/s13034-019-0276-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 03/12/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early identification of autism spectrum disorders (ASD) is a prerequisite for access to early interventions. Although parents often note developmental atypicalities during the first 2 years of life, many children with ASD are not diagnosed until school age. For parents, the long period between first parental concerns and diagnosis is often frustrating and accompanied by uncertainty and worry. METHODS This study retrospectively explored the trajectories of children with a confirmed ASD diagnosis during the diagnostic process, from first parental concerns about their child's development until the definite diagnosis. A survey concerning the diagnostic process was distributed to parents or legal guardians of children with ASD from three specialized ASD outpatient clinics in Germany. RESULTS The response rate was 36.9%, and the final sample consisted of carers of 207 affected children (83.6% male, mean age 12.9 years). The children had been diagnosed with childhood autism (55.6%), Asperger syndrome (24.2%), or atypical autism (20.3%). On average, parents had first concerns when their child was 23.4 months old, and an ASD diagnosis was established at a mean age of 78.5 months. Children with atypical autism or Asperger syndrome were diagnosed significantly later (83.9 and 98.1 months, respectively) than children with childhood autism (68.1 months). Children with an IQ < 85 were diagnosed much earlier than those with an IQ ≥ 85. On average, parents visited 3.4 different health professionals (SD = 2.4, range 1-20, median: 3.0) until their child received a definite ASD diagnosis. Overall, 38.5% of carers were satisfied with the diagnostic process. CONCLUSIONS In this sample of children with ASD in Germany, the time to diagnosis was higher than in the majority of other comparable studies. These results flag the need for improved forms of service provision and delivery for suspected cases of ASD in Germany.
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Affiliation(s)
- Juliana Höfer
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129 Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstr. 140, 26129 Oldenburg, Germany
| | - Inge Kamp-Becker
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps University Marburg, Hans-Sachs-Str. 4, 35039 Marburg, Germany
| | - Luise Poustka
- Department of Child and Adolescent Psychiatry, University Medical Center Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Germany
| | - Veit Roessner
- Department of Child and Adolescent Psychiatry, Medical Faculty of the Technical University Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Sanna Stroth
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps University Marburg, Hans-Sachs-Str. 4, 35039 Marburg, Germany
| | - Nicole Wolff
- Department of Child and Adolescent Psychiatry, Medical Faculty of the Technical University Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Christian J. Bachmann
- Department of Child and Adolescent Psychiatry, LVR-Klinikum Düsseldorf/Heinrich-Heine University Düsseldorf, Bergische Landstr. 2, 40629 Düsseldorf, Germany
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Mazurek MO, Curran A, Burnette C, Sohl K. ECHO Autism STAT: Accelerating Early Access to Autism Diagnosis. J Autism Dev Disord 2019; 49:127-137. [PMID: 30043354 DOI: 10.1007/s10803-018-3696-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although early diagnosis of autism is critical for promoting access to early intervention, many children experience significant diagnostic delays. Shortages of healthcare providers, limited capacity at autism centers, and geographic and socioeconomic challenges contribute to these delays. The current pilot study examined the feasibility of a new model for training community-based primary care providers (PCPs) in underserved areas in screening and diagnosis of young children at highest risk for autism. By combining hands-on training in standardized techniques with ongoing virtual mentorship and practice, the program emphasized both timely diagnosis and appropriate referral for more comprehensive assessment when necessary. Results indicated improvements in PCP practice and self-efficacy, and feasibility of the model for enhancing local access to care.
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Affiliation(s)
- Micah O Mazurek
- Department of Human Services, Curry School of Education, University of Virginia, 417 Emmet Street South, PO Box 400267, Charlottesville, VA, 22903, USA.
| | - Alicia Curran
- Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, MO, USA
| | - Courtney Burnette
- Center for Development and Disability, Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Kristin Sohl
- Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, MO, USA
- Department of Child Health, University of Missouri, Columbia, MO, USA
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A Pilot Project Using Pediatricians as Initial Diagnosticians in Multidisciplinary Autism Evaluations for Young Children. J Dev Behav Pediatr 2019; 40:1-11. [PMID: 30461593 DOI: 10.1097/dbp.0000000000000621] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Wait times for autism spectrum disorder (ASD) evaluations are long, thereby delaying access to ASD-specific services. We asked how our traditional care model (requiring all patients to see psychologists for ASD diagnostic decisions) compared to an alternative model that better utilizes the available clinicians, including initial evaluation by speech, audiology, and pediatrics (trained in Level 2 autism screening tools). Pediatricians could diagnose immediately if certain about diagnosis but could refer uncertain cases to psychology. Accuracy and time to diagnosis, charges, and parent satisfaction were our main outcome measures. METHODS Data were gathered through record extraction (n = 244) and parent questionnaire (n = 57). We compared time to diagnosis, charges, and parent satisfaction between traditional and alternative models. Agreement between pediatrician and psychologist diagnoses was examined for a subset (n = 18). RESULTS The alternative model's time to diagnosis was 44% faster (85 vs 152 d) and 33% less costly overall. Diagnostic agreement was 93% for children with ASD diagnoses and 100% for children without ASD diagnoses. Pediatricians expressed higher diagnostic certainty about children with higher levels of ASD symptoms. Parents reported no differences in high satisfaction with experiences, family-centered care, and shared decision making. CONCLUSION Efficient use of available clinicians with additional training in Level 2 autism screening resulted in improvements in time to diagnosis and reduced charges for families. Coordination of multidisciplinary teams makes this possible, with strategic sequencing of patients through workflow. Flexibility was key to not only allowing pediatricians to refer uncertain cases to psychology for diagnosis but also allowing for diagnosis by a pediatrician when symptomatic presentation clearly met diagnostic criteria.
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Ben-Sasson A, Atun-Einy O, Yahav-Jonas G, Lev-On S, Gev T. Training Physical Therapists in Early ASD Screening. J Autism Dev Disord 2018; 48:3926-3938. [PMID: 29971656 DOI: 10.1007/s10803-018-3668-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Physical therapists (PTs) are often one of the first professionals to evaluate children at risk. To examine the effect of an early screening training on pediatric PTs': (1) knowledge of autism spectrum disorder (ASD), (2) clinical self-efficacy, and (3) identification of markers. Twenty-six PTs participated in a 2-day "Early ASD Screening" workshop. The ASD Knowledge and Self-Efficacy Questionnaire, and video case study analysis were completed pre- and post-training. Changes following training were significant for ASD knowledge related to etiology and learning performance, early signs, risk factors, and clinical self-efficacy. Rating the videoed case study after the training, was significantly more accurate than it was before. Training PTs is important for enhancing early identification of ASD.
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Affiliation(s)
- Ayelet Ben-Sasson
- Department of Occupational Therapy, University of Haifa, 3498838, Haifa, Israel.
| | - Osnat Atun-Einy
- Department of Physical Therapy, University of Haifa, 3498838, Haifa, Israel
| | - Gal Yahav-Jonas
- Association for Children at Risk, 9 Hazvi St., Tel Aviv, 67197, Israel
| | - Shimona Lev-On
- Weinberg Child Development Center, Sheba Tel-Hashomer Hospital, Ramat Gan, 52621, Israel
| | - Tali Gev
- Department of Psychology, Bar-Ilan University, Ramat Gan, 5290002, Israel
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Shahidullah JD, Azad G, Mezher KR, McClain MB, McIntyre LL. Linking the Medical and Educational Home to Support Children With Autism Spectrum Disorder: Practice Recommendations. Clin Pediatr (Phila) 2018; 57:1496-1505. [PMID: 29719986 DOI: 10.1177/0009922818774344] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Children with autism spectrum disorder (ASD) present with complex medical problems that are often exacerbated by a range of other intellectual and psychiatric comorbidities. These children receive care for their physical and mental health from a range of providers within numerous child-serving systems, including their primary care clinic, school, and the home and community. Given the longitudinal nature in which care is provided for this chronic disorder, it is particularly necessary for services and providers to coordinate their care to ensure optimal efficiency and effectiveness. There are 2 primary venues that serve as a "home" for coordination of service provision for children with ASD and their families-the "medical home" and the "educational home." Unfortunately, these venues often function independently from the other. Furthermore, there are limited guidelines demonstrating methods through which pediatricians and other primary care providers (PCPs) can coordinate care with schools and school-based providers. The purpose of this article is 2-fold: (1) we highlight the provision of evidence-based care within the medical home and educational home and (2) we offer practice recommendations for PCPs in integrating these systems to optimally address the complex medical, intellectual, and psychiatric symptomology affected by autism.
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Affiliation(s)
- Jeffrey D Shahidullah
- 1 Rutgers University, New Brunswick, NJ, USA and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Gazi Azad
- 2 Johns Hopkins University, Baltimore, MD, USA and Kennedy Krieger Institute, Baltimore, MD, USA
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Accuracy of Reported Community Diagnosis of Autism Spectrum Disorder. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2018; 40:367-375. [PMID: 30270970 DOI: 10.1007/s10862-018-9642-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To compare community diagnoses of Autism Spectrum Disorder (ASD) reported by parents to consensus diagnoses made using standardized tools plus clinical observation. 87 participants (85% male, average age 7.4 years), with reported community diagnosis of ASD were evaluated using the Autism Diagnostic Observation Schedule) (ADOS-2), Differential Ability Scale (DAS-II), and Vineland Adaptive Behavior Scales (VABS-II). Detailed developmental and medical history was obtained from all participants. Diagnosis was based on clinical consensus of at least two expert clinicians, using test results, clinical observations, and parent report. 23% of participants with a reported community diagnosis of ASD were classified as non-spectrum based on our consensus diagnosis. ASD and non-spectrum participants did not differ on age at evaluation and age of first community diagnosis. Non-verbal IQ scores and Adaptive Behavior Composite scores were significantly higher in the non-spectrum group compared to the ASD group (104.5 ± 21.7 vs. 80.1 ± 21.6, p < .01; 71.1 ± 15 versus 79.5 ± 17.6, p < .05, respectively). Participants enrolled with community diagnosis of PDD-NOS were significantly more likely to be classified as non-spectrum on the study consensus diagnosis than Participants with Autism or Asperger (36% versus 9.5%, Odds Ratio = 5.4, p < .05). This study shows suboptimal agreement between community diagnoses of ASD and consensus diagnosis using standardized instruments. These findings are based on limited data, and should be further studied, taking into consideration the influence of DSM 5 diagnostic criteria on ASD prevalence.
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Morris R, Muskat B, Greenblatt A. Working with children with autism and their families: pediatric hospital social worker perceptions of family needs and the role of social work. SOCIAL WORK IN HEALTH CARE 2018; 57:483-501. [PMID: 29667506 DOI: 10.1080/00981389.2018.1461730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Social workers with knowledge of autism can be valuable contributors to client- and family-centered healthcare services. This study utilized a qualitative design to explore pediatric hospital social workers' experiences and perceptions when working with children and youth with autism and their families. Interviews with 14 social workers in a Canadian urban pediatric hospital highlighted perceptions of the needs of families of children with autism in the hospital and challenges and benefits related to the role of social work with these families. Results suggest that pediatric social workers may benefit from opportunities to develop autism-relevant knowledge and skills.
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Affiliation(s)
- Rae Morris
- a The Redpath Centre , Toronto , Canada
- b School of Social Work , University of British Columbia , Vancouver , Canada
| | - Barbara Muskat
- c Department of Social Work , The Hospital for Sick Children , Toronto , Canada
| | - Andrea Greenblatt
- c Department of Social Work , The Hospital for Sick Children , Toronto , Canada
- d Factor-Inwentash Faculty of Social Work , University of Toronto , Toronto , Canada
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Suma K, Adamson LB, Bakeman R, Robins DL, Abrams DN. After Early Autism Diagnosis: Changes in Intervention and Parent-Child Interaction. J Autism Dev Disord 2017; 46:2720-2733. [PMID: 27193183 DOI: 10.1007/s10803-016-2808-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study documents the relation between an autism spectrum disorder (ASD) diagnosis, increases in intervention, and changes in parent-child interaction quality. Information about intervention and observations of interaction were collected before diagnosis and a half year after diagnosis for 79 low-risk toddlers who had screened positive for ASD risk during a well-baby checkup. Children diagnosed with ASD (n = 44) were 2.69 times more likely to increase intervention hours. After ASD diagnosis, the relation between intervention and interaction quality was complex: although increases in intervention and interaction quality were only modestly related, the overall amount of intervention after diagnosis was associated with higher quality interactions. Moreover, lower quality interactions before diagnosis significantly increased the likelihood that intervention would increase post-diagnosis.
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Affiliation(s)
- Katharine Suma
- Department of Psychology, Georgia State University, Atlanta, GA, 30303-5010, USA
| | - Lauren B Adamson
- Department of Psychology, Georgia State University, Atlanta, GA, 30303-5010, USA.
| | - Roger Bakeman
- Department of Psychology, Georgia State University, Atlanta, GA, 30303-5010, USA
| | - Diana L Robins
- AJ Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
| | - Danielle N Abrams
- Department of Psychology, Georgia State University, Atlanta, GA, 30303-5010, USA
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50
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Pijl MK, Buitelaar JK, de Korte MW, Rommelse NN, Oosterling IJ. Sustainability of an early detection program for autism spectrum disorder over the course of 8 years. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2017; 22:1018-1024. [PMID: 29068245 PMCID: PMC6196591 DOI: 10.1177/1362361317717977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The importance of early detection of autism spectrum disorder followed by early intervention is increasingly recognized. This quasi-experimental study evaluated the long-term effects of a program for the early detection of autism spectrum disorder (consisting of training of professionals and use of a referral protocol and screening instrument), to determine whether the positive effects on the age at referral were sustained after the program ended while controlling for overall changes in the number of referrals. Before, during, and after the program, the proportion of children referred before 3 years (versus 3–6 years) of age was calculated for children subsequently diagnosed with autism spectrum disorder (N = 513) or another, non-autism spectrum disorder, condition (N = 722). The odds of being referred before 3 years of age was higher in children with autism spectrum disorder than in children with another condition during the program than before (3.1, 95% confidence interval: 1.2–7.6) or after (1.7, 95% confidence interval: 1.0–3.0) the program but was not different before versus after the program. Thus, although the program led to earlier referral of children with autism spectrum disorder, after correction for other referrals, the effect was not sustained after the program ended. This study highlights the importance of continued investment in the early detection of autism spectrum disorder.
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Affiliation(s)
- Mirjam Kj Pijl
- 1 Karakter Child and Adolescent Psychiatry University Centre, The Netherlands.,2 Radboud University Medical Centre, Nijmegen
| | - Jan K Buitelaar
- 1 Karakter Child and Adolescent Psychiatry University Centre, The Netherlands.,2 Radboud University Medical Centre, Nijmegen
| | - Manon Wp de Korte
- 1 Karakter Child and Adolescent Psychiatry University Centre, The Netherlands.,2 Radboud University Medical Centre, Nijmegen
| | - Nanda Nj Rommelse
- 1 Karakter Child and Adolescent Psychiatry University Centre, The Netherlands.,2 Radboud University Medical Centre, Nijmegen
| | - Iris J Oosterling
- 1 Karakter Child and Adolescent Psychiatry University Centre, The Netherlands.,2 Radboud University Medical Centre, Nijmegen
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