1
|
Huntjens A, van den Bosch LMCW, Sizoo B, Kerkhof A, Smit F, van der Gaag M. The effectiveness and safety of dialectical behavior therapy for suicidal ideation and behavior in autistic adults: a pragmatic randomized controlled trial. Psychol Med 2024:1-12. [PMID: 38606582 DOI: 10.1017/s0033291724000825] [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: 04/13/2024]
Abstract
BACKGROUNDS Many autistic people in mental health are suicidal. This study evaluated the effectiveness of dialectical behavior therapy (DBT) v. treatment as usual (TAU) in reducing suicidal ideation and suicide attempts. METHODS At six Dutch mental health centers, 123 outpatients (18-65 years) with DSM-5 diagnosed autism spectrum disorder (ASD) and suicidal behavior were randomly assigned to the DBT intervention group (n = 63) or TAU control group (n = 60). Assessments were conducted at baseline, post-treatment at 6 months and 12-month follow-up. The primary outcomes were severity of suicidal ideation and frequency of suicide attempts. The severity of depression and social anxiety were secondary outcomes. RESULTS At end-of-treatment, DBT significantly reduced both suicidal ideation (z = -2.24; p = 0.025; b = -4.41; s.e. = 197.0) and suicide attempts (z = -3.15; p = 0.002; IRR = 0.046; s.e. = 0.045) compared to TAU, but lost statistical significance at the 12-month follow-up. Depression severity significantly decreased with DBT (z = -1.99; p = 0.046: b = -2.74; s.e. = 1.37) remaining so at 12 months (z = -2.46; p = 0.014; b = -3.37; s.e. = 1.37). No effects were observed on social anxiety. Severe adverse events included two suicides in the TAU condition. CONCLUSIONS DBT is an acceptable, safe, and short-term effective intervention to reduce suicidal ideation and suicide attempts in autistic adults with suicidal behavior.
Collapse
Affiliation(s)
- Anne Huntjens
- Department of Clinical Psychology and Public Mental Health Research Institute, Vrije Universiteit, Amsterdam, Netherlands
- Parnassia Psychiatric Institute, The Hague, Netherlands
| | | | | | - Ad Kerkhof
- Department of Clinical Psychology and Public Mental Health Research Institute, Vrije Universiteit, Amsterdam, Netherlands
| | - Filip Smit
- Department of Clinical Psychology and Public Mental Health Research Institute, Vrije Universiteit, Amsterdam, Netherlands
| | - Mark van der Gaag
- Department of Clinical Psychology and Public Mental Health Research Institute, Vrije Universiteit, Amsterdam, Netherlands
- Parnassia Psychiatric Institute, The Hague, Netherlands
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
White SW, Schall C, Santos JD, Maddox BB, Hillier A, Klinger L, Pugliese C. Promoting Quality of Life: Suggestions for Mental Health Care Providers Working with Young Autistic Adults. AUTISM IN ADULTHOOD 2023; 5:347-355. [PMID: 38116052 PMCID: PMC10726189 DOI: 10.1089/aut.2022.0106] [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: 03/29/2023]
Abstract
There is a growing population of autistic adults in need of supports from a service delivery system that, at present, fails to accommodate their needs adequately and equitably. Unfortunately, there is a shortage of trained behavioral health service providers to meet the needs of young autistic adults. Quality of life (QoL), or one's perception of, and satisfaction with, life in relation to held goals and expectations, has been identified as a key outcome of interest by autistic self-advocates. By supporting autistic clients to hone their strengths and interests, integrate various aspects of their identity, identify goals, and connect to appropriate resources, providers can promote clients' self-knowledge and self-determination, in the service of improving QoL. In this Perspectives article, we offer concrete recommendations to mental health providers, including those who do not specialize in autism, with the goal of supporting implementation of evidence-based strategies that improve QoL and promote self-determination among young autistic clients.
Collapse
Affiliation(s)
- Susan W. White
- Center for Youth Development and Intervention, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Carol Schall
- Autism Center for Education, Rehabilitation Research and Training Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jin Delos Santos
- Project REACH, College of Staten Island at the City University of New York, Staten Island, New York, USA
| | - Brenna B. Maddox
- TEACCH Autism Program, Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ashleigh Hillier
- Department of Psychology, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Laura Klinger
- TEACCH Autism Program, Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cara Pugliese
- Center for Autism Spectrum Disorders, Children's National Hospital, Washington, District of Columbia, USA
| |
Collapse
|
4
|
Jubenville-Wood T, Nicholas DB, Weiss J, Cairns S. Mental Health Providers' Perspectives on What Helps and Hinders in Psychotherapy for Autistic Adults with Co-occurring Mental Health Problems. J Autism Dev Disord 2023:10.1007/s10803-023-06143-y. [PMID: 37856002 DOI: 10.1007/s10803-023-06143-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: 09/18/2023] [Indexed: 10/20/2023]
Abstract
Autistic adults experience disproportionate rates of co-occurring mental health problems. Psychotherapy has been recognized as an appropriate treatment approach, but evidence is limited. Researchers used a qualitative research paradigm to explore the experiences of mental health providers who provide psychotherapy to autistic adults. The Enhanced Critical Incident Technique was used to interview 13 mental health providers regarding perceptions of facilitating therapy with autistic adults. This research highlights challenges to providing psychotherapy to autistic adults while also illuminating ways that mental health providers have worked to ameliorate such challenges and create positive experiences in therapy. This research also contrasts therapy for autistic adults relative to the general population. Practice recommendations and suggestions for future research are offered.
Collapse
|
5
|
Kirby L, Payne KL. Knowledge of autism gained by learning from people through a local UK Autism Champion Network: A health and social care professional perspective. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2023; 27:13623613231167902. [PMID: 37131289 PMCID: PMC10576896 DOI: 10.1177/13623613231167902] [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: 05/04/2023]
Abstract
LAY ABSTRACT The Autism Act 10 Years On found few autistic adults thought health and social care professionals had a good understanding of autism. Autism training has been made law in the United Kingdom for health and social care staff to tackle health inequality. The county wide Autism Champion Network evaluated here is an equal partnership of interested staff across sectors (Autism Champions) and autistic experts by virtue of lived experience (Autism Advisory Panel). With knowledge flowing both ways, the Autism Champions take learning back to teams to support continuous development of services to meet autistic need. Seven health and social sector professionals from the Network participated in semi-structured interviews on sharing knowledge of autism gained with their teams. All participants provide care and support for autistic people, some working in specialist positions. Results showed that developing new relationships with people outside their own team to signpost to, answer questions and share resources, and informal learning from autistic people, was more valued and used in practice than information gained from presentations. These results have implications in developing learning for those who need above a basic knowledge of autism and may be useful for others considering setting up an Autism Champion Network.
Collapse
|
6
|
Wigham S, Ingham B, Le Couteur A, Wilson C, Ensum I, Parr JR. Consensus statements on optimal adult post-autism diagnosis support and services: Delphi process following a UK survey of autistic adults, relatives and clinicians. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2023; 27:344-355. [PMID: 35670069 DOI: 10.1177/13623613221097502] [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: 02/02/2023]
Abstract
LAY ABSTRACT Research has identified types of support helpful to autistic people, for example, physical and mental health interventions, psycho-education, peer support, developing positive identities and affiliation with social groups. However, accessing suitable post-autism diagnosis support and services is extremely difficult. We asked autistic adults, relatives and clinicians about their experiences of receiving and delivering post-autism diagnosis support/services. In Stage 1, 343 autistic adults and 45 relatives completed a survey. They answered questions about their experiences of UK autism post-diagnosis support/services for adults within 12 months after receiving a diagnosis. Thirty-five clinicians completed a similar survey. Just over half of adults and relatives said there was a follow-up appointment or discussion about support after diagnosis. Fewer than 40% received any support/services in 12 months after diagnosis. We used information from the surveys to create 11 statements describing characteristics of appropriate adult post-autism diagnosis support/services. In Stage 2, we asked clinicians for their views on the statements - they agreed with all of them. For example, those adults are offered an additional follow-up meeting after diagnosis and have access to mental and physical health services. We shared results with autistic adults, relatives and clinicians at two events. Some autistic adults, relatives and clinicians were positive about post-autism diagnosis support/services. However, they described many areas for improvement. The study findings can be used to define, develop and improve the types of adult post-diagnosis support services.
Collapse
Affiliation(s)
- Sarah Wigham
- Population Health Sciences Institute, Newcastle University, UK
| | - Barry Ingham
- Population Health Sciences Institute, Newcastle University, UK.,Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, UK
| | - Ann Le Couteur
- Population Health Sciences Institute, Newcastle University, UK
| | - Colin Wilson
- Population Health Sciences Institute, Newcastle University, UK
| | - Ian Ensum
- Avon and Wiltshire Mental Health Partnership NHS Trust, UK
| | - Jeremy R Parr
- Population Health Sciences Institute, Newcastle University, UK.,Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, UK
| |
Collapse
|
7
|
Roudbarani F, Tablon Modica P, Maddox BB, Bohr Y, Weiss JA. Clinician factors related to the delivery of psychotherapy for autistic youth and youth with attention-deficit hyperactivity disorder. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2023; 27:415-427. [PMID: 35786029 DOI: 10.1177/13623613221106400] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
LAY ABSTRACT Autistic children and youth often experience mental health problems, such as anxiety, depression and behavioural challenges. Although there are therapy programmes that have been found helpful in reducing these issues, such as cognitive behaviour therapy, autistic children often struggle to receive adequate mental health care. Clinicians' knowledge, attitudes, confidence and beliefs about treating mental health problems in autistic people may be related to their choices in providing psychotherapy. Across Ontario, Canada, 611 mental health clinicians, working in publicly funded agencies, completed an online survey about their experiences and opinions on delivering therapy for autistic clients compared to those with attention-deficit hyperactivity disorder. Clinician knowledge was associated with their intention to treat autistic clients or clients with attention-deficit hyperactivity disorder, partly because of their attitudes and the social pressures or values they felt. Clinicians reported feeling less intent on providing therapy to autistic youth compared to youth with attention-deficit hyperactivity disorder because of differences in their attitudes, social pressures and knowledge. This research can inform the training and educational initiatives for mental health practitioners.
Collapse
|
8
|
Bury SM, Haschek A, Wenzel M, Spoor JR, Hedley D. Brief Report: Learning About Autism: Is the Source of Autism Knowledge Associated with Differences in Autism Knowledge, Autism Identity, and Experiences of Stigma. J Autism Dev Disord 2022:10.1007/s10803-022-05823-5. [PMID: 36443495 DOI: 10.1007/s10803-022-05823-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/29/2022]
Abstract
People on the autism spectrum can learn about autism from various sources, likely differing in the information, portrayal, and discussion they offer. The present study investigates where autistic people learn about autism, and whether their information source is associated with their level of autism knowledge, perceptions of stigma, and development and expression of an autism identity. A survey of 198 Australian adults with an autism diagnosis showed that learning about autism from conventional sources (e.g., professionals, parents) was associated with more internalised stigma, lower endorsement of special abilities and autism identity, whereas online blogs and social media showed the opposite pattern as well as more accurate knowledge of autism. The findings raise questions about how authoritative sources of information discuss autism.
Collapse
Affiliation(s)
- Simon M Bury
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, 3086, Australia.
| | - Alex Haschek
- Olga Tennison Autism Research Centre, La Trobe University, Melbourne, VIC, Australia
| | - Michael Wenzel
- College of Education, Psychology and Social Work, Flinders University, Adelaide, Australia
| | - Jennifer R Spoor
- Olga Tennison Autism Research Centre, La Trobe University, Melbourne, VIC, Australia
- La Trobe Business School, College of Arts, Social Sciences and Commerce, La Trobe University, Melbourne, Australia
| | - Darren Hedley
- Olga Tennison Autism Research Centre, La Trobe University, Melbourne, VIC, Australia
| |
Collapse
|
9
|
Recommended adaptations to therapy services for autistic adults from specialist clinicians. CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-022-04034-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
10
|
Coughlan B, Woolgar M, Weisblatt EJ, Duschinsky R. 'Instruments are good at eliciting information; scores are very dangerous': The perspectives of clinical professionals regarding neurodevelopmental assessment. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2022; 27:905-915. [PMID: 36154304 PMCID: PMC10115934 DOI: 10.1177/13623613221121413] [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: 11/17/2022]
Abstract
LAY ABSTRACT Autism and attention deficit hyperactivity disorder are common behaviourally diagnosed conditions. One of the key aspects of diagnosis is clinical judgement. Yet despite decades of research, it is only in recent times that researchers have started exploring clinicians' perspectives on diagnosing these conditions. We aimed to add to this body of knowledge by conducting interviews with 17 experienced health care professionals in the United Kingdom to hear their perspectives on diagnosing autism and attention deficit hyperactivity disorder. Clinicians reflected that for some children and young people, diagnosis is reasonably straightforward; however, in other situations, decisions are made on more pragmatic grounds (i.e. will this be helpful). We identified some differences of opinion between professionals and organisation which adds to the complexity of applying a diagnosis. We recommend several areas for future research and point to some practical and philosophical implications of the work.
Collapse
Affiliation(s)
| | | | - Emma Jl Weisblatt
- University of Cambridge, UK.,Cambridgeshire and Peterborough NHS Foundation Trust, UK
| | | |
Collapse
|
11
|
Pellicano E, Fatima U, Hall G, Heyworth M, Lawson W, Lilley R, Mahony J, Stears M. A capabilities approach to understanding and supporting autistic adulthood. NATURE REVIEWS PSYCHOLOGY 2022; 1:624-639. [PMID: 36090460 PMCID: PMC9443657 DOI: 10.1038/s44159-022-00099-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 12/28/2022]
Abstract
There is little comprehensive research into autistic adulthood, and even less into the services and supports that are most likely to foster flourishing adult autistic lives. This limited research is partly because autism is largely conceived as a condition of childhood, but this focus of research has also resulted from the orthodox scientific approach to autism, which conceptualizes autistic experience almost entirely as a series of biologically derived functional deficits. Approaching autism in this way severely limits what is known about this neurodevelopmental difference, how research is conducted and the services and supports available. In this Review, we adopt an alternative research strategy: we apply Martha Nussbaum’s capabilities approach, which focuses on ten core elements of a thriving human life, to research on autistic adulthood. In doing so, we identify areas where autistic adults thrive and where they often struggle, and highlight issues to which researchers, clinicians and policymakers should respond. The resulting picture is far more complex than conventional accounts of autism imply. It also reveals the importance of engaging autistic adults directly in the research process to make progress towards genuinely knowing autism and supporting flourishing autistic lives. The focus on functional deficits in conventional autism research constrains understanding of autistic lives. In this Review, Pellicano et al. appraise research on autistic adulthood through a capabilities lens to identify areas where autistic adults thrive, and where more research and services are needed to enhance their quality of life.
Collapse
|
12
|
Dwyer S, Rogan A. Seeing the unseen: Neurodiversity in the emergency department. Emerg Med Australas 2022; 34:609-612. [PMID: 35785441 DOI: 10.1111/1742-6723.14038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Sophie Dwyer
- Australasian Faculty of Public Health Medicine Specialist Training Program, Sydney, New South Wales, Australia
| | - Alice Rogan
- Te Pae Tiaki/Emergency Department, Wellington Regional Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| |
Collapse
|
13
|
McCowan S, Shaw SCK, Doherty M, Grosjean B, Blank P, Kinnear M. A full CIRCLE: inclusion of autistic doctors in the Royal College Of Psychiatrists' values and Equality Action Plan. Br J Psychiatry 2022; 221:371-373. [PMID: 35152922 DOI: 10.1192/bjp.2022.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Autistic psychiatrists bring strengths and values to the workforce and ask to be acknowledged and supported as part of the Royal College of Psychiatrists' CIRCLE values and Equality Action Plan. Courage and collaboration are required to jointly learn and innovate, promoting well-being, resilience and excellence for autistic doctors.
Collapse
Affiliation(s)
- Sue McCowan
- Dorset Healthcare University Foundation Trust, UK
| | | | | | | | | | | |
Collapse
|
14
|
Turnock A, Langley K, Jones CR. Understanding Stigma in Autism: A Narrative Review and Theoretical Model. AUTISM IN ADULTHOOD 2022; 4:76-91. [PMID: 36605561 PMCID: PMC8992913 DOI: 10.1089/aut.2021.0005] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The experience of stigma by autistic people is relatively understudied, despite contributing to a range of poor outcomes and having an overarching impact on well-being. The current review of the literature synthesizes research to determine what is currently known and presents a theoretical model of autism stigma. Autism stigma is primarily influenced by a public and professional understanding of autism in combination with interpretation of visible autistic traits. Moderating factors include the quality and quantity of contact with autistic people, cultural factors, sex and gender, individual differences, and diagnostic disclosure. Stigma can reduce well-being as well as increase the presence of camouflaging behaviors, which mask autistic traits. Caregivers of autistic people can experience stigma by association, that is, affiliate stigma, which can impact their own well-being. A variety of interventions and approaches to reduce stigma are discussed, including "autism friendly" spaces, positive media representation, educational and psychosocial training for the public and professionals, as well as cultural and systemic shifts that foster inclusivity and recognize neurodiversity.
Collapse
Affiliation(s)
- Alice Turnock
- School of Medicine, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Kate Langley
- Wales Autism Research Centre, School of Psychology, Cardiff University, Cardiff, United Kingdom
| | - Catherine R.G. Jones
- Wales Autism Research Centre, School of Psychology, Cardiff University, Cardiff, United Kingdom.,Address correspondence to: Catherine R.G. Jones, PhD, School of Psychology, Cardiff University, Park Place, Cardiff CF10 3AT, United Kingdom
| |
Collapse
|
15
|
Mandy W. Six ideas about how to address the autism mental health crisis. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2022; 26:289-292. [PMID: 35109701 DOI: 10.1177/13623613211067928] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
16
|
Brede J, Cage E, Trott J, Palmer L, Smith A, Serpell L, Mandy W, Russell A. “We Have to Try to Find a Way, a Clinical Bridge” - autistic adults' experience of accessing and receiving support for mental health difficulties: A systematic review and thematic meta-synthesis. Clin Psychol Rev 2022; 93:102131. [DOI: 10.1016/j.cpr.2022.102131] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 12/04/2021] [Accepted: 01/28/2022] [Indexed: 12/28/2022]
|
17
|
Fridell A, Norrman HN, Girke L, Bölte S. Effects of the Early Phase of COVID-19 on the Autistic Community in Sweden: A Qualitative Multi-Informant Study Linking to ICF. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031268. [PMID: 35162290 PMCID: PMC8835079 DOI: 10.3390/ijerph19031268] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 02/04/2023]
Abstract
While the COVID-19 pandemic is ongoing, early outcome studies indicate severe and pervasive global effects of the pandemic and associated measures to prevent the spread of the virus. General population studies, as well as insight into the outcomes for particular groups, will be necessary in order to mitigate potentially long-term effects as well as to prepare for future epidemics or pandemics. The pandemic conditions have been marked by rapid and abrupt changes and unpredictability which are circumstances that leave the autistic population particularly vulnerable to adverse outcomes following the distinctive features of the diagnosis. Studies are only beginning to delineate the outcomes of the global autism community and the present study adds to these findings by providing a local, multi-perspective, qualitative analysis of the lived experiences of the Swedish autism community. In this study, autistic youth and adults, caregivers of autistic individuals, as well as representatives of Swedish interest organizations were interviewed. Thematic analysis was performed on the population as a whole and patterns of results were formalized according to the International Classification of Function, Disability and Health (ICF-CY). Participants report wide-ranging adverse outcomes of the pandemic relating to mental health and access to support, participation in daily activities and socialization, education, and work as well as parental resources. However, participants also report positive outcomes relating to a reduction in specific social and everyday demands, and normalization of lived experiences. Additionally, interviews outlined some strategies used to cope during pandemic conditions. Implications of these findings are discussed.
Collapse
Affiliation(s)
- Anna Fridell
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women’s and Children’s Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, 113 30 Stockholm, Sweden; (H.N.N.); (L.G.); (S.B.)
- Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm,118 61 Stockholm, Sweden
- Curtin Autism Research Group, Curtin School of Allied Health, Curtin University, Perth, WA 6102, Australia
- Correspondence:
| | - Hjalmar Nobel Norrman
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women’s and Children’s Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, 113 30 Stockholm, Sweden; (H.N.N.); (L.G.); (S.B.)
| | - Linda Girke
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women’s and Children’s Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, 113 30 Stockholm, Sweden; (H.N.N.); (L.G.); (S.B.)
- Department of Psychology, Developmental Psychology, Uppsala University, 751 05 Uppsala, Sweden
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women’s and Children’s Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, 113 30 Stockholm, Sweden; (H.N.N.); (L.G.); (S.B.)
- Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm,118 61 Stockholm, Sweden
- Curtin Autism Research Group, Curtin School of Allied Health, Curtin University, Perth, WA 6102, Australia
| |
Collapse
|
18
|
Naicker VV, Bury SM, Hedley D. Factors associated with parental resolution of a child's autism diagnosis: A systematic review. Front Psychiatry 2022; 13:1079371. [PMID: 36683975 PMCID: PMC9849876 DOI: 10.3389/fpsyt.2022.1079371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Receiving a child's autism diagnosis can be stressful; as such, parent resolution contributes to the wellbeing and development of healthy parent-child relationships. In other significant childhood diagnoses (e.g., cerebral palsy, diabetes), the degree to which parents adjust to (a) their child's diagnosis and (b) their changes in expectations concerning their child's development and capacity (referred to as resolution to diagnosis), has been associated with improved outcomes including facilitating parent-child relationships and improved parental wellbeing. Given potential benefits to parent and child, and the heterogenous nature of autism, examining the unique factors associated with resolution to diagnosis is important. In this systematic review we identified factors that support or inhibit parental resolution to their child receiving a diagnosis of autism. METHODS We completed a systematic review following PRISMA guidelines of peer-reviewed studies from 2017 to 2022, that investigated parental resolution or acceptance of an autism diagnosis. Papers including "acceptance" needed to encompass both accepting the diagnosis and the implications regarding the child's abilities. We searched six databases (Scopus, Web of Science, MEDLINE, PsycINFO, ProQuest), with additional papers located following review of reference lists. RESULTS Fourteen papers with 592 participants that investigated parental resolution or acceptance of an autism diagnosis, were included. We identified six common factors that facilitate or inhibit parental resolution and acceptance of an autism diagnosis including: symptom severity; religion, belief, and culture; knowledge and uncertainty; negative emotions (i.e., denial, shame, guilt); positive emotions; and support. Greater resolution was associated with improved "attunement and insightfulness" in the parent-child relationship. LIMITATION The review was limited by the small number of studies meeting inclusion criteria. Second, the quality of included studies was mixed, with over half of the studies being qualitative and only one randomized control trial (RCT) identified. CONCLUSION Parental resolution can have an impact on parent's perception of their child's capabilities and impact the parent-child relationship. We identified six categories that aid in inhibiting or promoting resolution to diagnosis. Despite taking a broad approach on the definition of resolution, the low number of studies identified in the review indicates a need for more research in this area. SYSTEMATIC REVIEW REGISTRATION http://www.crd.york.ac.uk/PROSPERO/, PROSPERO [ID: CRD42022336283].
Collapse
Affiliation(s)
- Vrinda V Naicker
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Simon M Bury
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Darren Hedley
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| |
Collapse
|
19
|
Abstract
Recognition of autism and the associated co-occurring physical and mental health issues has increased over recent years. However, undergraduate and postgraduate curricula take time to adapt and to impact on what is delivered in training so healthcare professionals, including doctors, report little training on these topics. Doctors need to know when someone might be autistic in order to respond to them appropriately. This article sets out the reasons why recognition of autism is important and the positive impacts of recognising and understanding autism on health outcomes, service delivery and patient experience. The negative consequences of not recognising autism or understanding the impact of autistic traits on the person are also explored. A companion article then covers how practice can be made more appropriate for autistic people to improve outcomes.
Collapse
Affiliation(s)
- Mary Doherty
- Department of Anaesthesia, Our Lady's Hospital, Navan, Ireland
| | - Clair Haydon
- Department of Adult Autism Services, Cheshire and Wirral Partnership NHS Foundation Trust and Centre for Autism, Neuro-Developmental Disorders and Intellectual Disability (CANDDID), Chester, UK
| | - Ian A Davidson
- Department of Adult Mental Health, Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
| |
Collapse
|
20
|
Rahbar MH, Dobrescu I, Gillani S, Hessabi M, Kim S, Stancu M, Rad F. Construct validity for the self-reported competency and sub-construct associated characteristics of Romanian physicians in autism spectrum disorder. BMC MEDICAL EDUCATION 2021; 21:588. [PMID: 34801018 PMCID: PMC8605522 DOI: 10.1186/s12909-021-02999-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Lack of physicians' knowledge regarding mental health, including Autism Spectrum Disorder (ASD) could have adverse effects on affected individuals' health and quality of life. The purpose of this study was to provide construct validity for a modified questionnaire in order to determine the self-reported competency for underlying sub-constructs in ASD, make inferences on perceived competence in ASD based on a sample of Romanian physicians, and identify physicians' characteristics associated with these sub-domains of competency. METHODS For this survey, we modified a questionnaire that was used in Pakistan and Turkey, and administered it to a sample of 383 practicing physicians in Romania to assess their perceived competency regarding ASD. Exploratory factor analysis on 12 knowledge questions revealed five sub-domains: stigma, potential causes, children's behavior, misconceptions, and educational needs associated with ASD knowledge. Using General Linear Models, we determined physicians' characteristics that predict the total competency score and various competency sub-scores. RESULTS Seventy-five percent of the responding physicians were female and 30% had over 30 years practicing medicine. The majority (73-94%) of physicians have correctly responded to some basic questions regarding knowledge about ASD. We also found that younger physicians were more knowledgeable about potential causes of ASD than older physicians (Adjusted Mean Score (AMS): 2.90 vs. 2.18, P < 0.01), while older physicians knew more about the behavior of children with ASD (AMS: 0.64 vs. 0.37, P = 0.02). We found a significant interaction (P < 0.01) between television as source of ASD knowledge and city where the clinic is located in relation to knowledge of the physicians regarding stigma related to ASD. However, the total score was not associated with the variables associated with sub-domains. CONCLUSION Using factor analysis, we demonstrated construct validity of five sub-domains related to Romanian physicians' knowledge about ASD that include stigma, potential causes, behavior in ASD children, special education needs, and misconceptions related to ASD. The lack of significant association of the knowledge of physicians on ASD neither with the Psychiatry nor the Pediatric ward rotations at medical school may support the need for improving the curriculum on ASD in Romanian medical schools.
Collapse
Affiliation(s)
- Mohammad H. Rahbar
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 1100.05, UT Professional Building, Houston, TX 77030 USA
- Biostatistics/Epidemiology/Research Design (BERD) core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 1100.05, UT Professional Building, Houston, TX 77030 USA
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX 77030 USA
| | - Iuliana Dobrescu
- Child and Adolescent Psychiatry Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Child and Adolescent Psychiatry, “Prof. Dr.Alex. Obregia” Psychiatry Hospital, Bucharest, Romania
| | - Shezeen Gillani
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX 77030 USA
| | - Manouchehr Hessabi
- Biostatistics/Epidemiology/Research Design (BERD) core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 1100.05, UT Professional Building, Houston, TX 77030 USA
| | - Sori Kim
- Biostatistics/Epidemiology/Research Design (BERD) core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 1100.05, UT Professional Building, Houston, TX 77030 USA
- Department of Biostatistics & Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX USA
| | - Mihaela Stancu
- Child and Adolescent Psychiatry Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Child and Adolescent Psychiatry, “Prof. Dr.Alex. Obregia” Psychiatry Hospital, Bucharest, Romania
| | - Florina Rad
- Child and Adolescent Psychiatry Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Child and Adolescent Psychiatry, “Prof. Dr.Alex. Obregia” Psychiatry Hospital, Bucharest, Romania
| |
Collapse
|
21
|
McMillion A, Tobiansky B, Wang K, Cronin AJ, Johnson A, Monteiro J, Remington A. UK-based specialist dental professionals' experiences of working with autistic patients. SPECIAL CARE IN DENTISTRY 2021; 42:120-136. [PMID: 34582574 DOI: 10.1111/scd.12653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 01/02/2023]
Abstract
AIMS Previous research has demonstrated that autistic individuals often experience difficulties accessing dental care, both as a result of autism specific difficulties and practitioners' attitudes towards autism. However, very little research exists that explores dental professionals' experiences of providing care to their autistic patients. The aim of this study was to investigate the strategies UK-based dental professionals' use when working with autistic patients METHODS AND RESULTS: In this study, dental professionals (n = 16) from a variety of specialty roles (special care, paediatrics, orthodontics) were interviewed. We asked participants to talk through, in depth, specific cases they had encountered in their practice, what sorts of accommodations they had provided, and what concerns had arisen during appointments. Thematic analysis was used to analyses the data and revealed four main themes: the unique dental needs associated with being autistic, effective adaptations to practice, the crucial role of the caregiver, and the importance of specialist knowledge CONCLUSION: Recommendations for how dentists can improve the dental experiences of autistic patients can be drawn from the specialist dentists' responses in this study. These include involving autistic patients in decisions about their treatment and being flexible and willing to work with autistic patients and their caregivers.
Collapse
Affiliation(s)
- Audrey McMillion
- Deparatment of Psychology and Human Development, UCL Institute of Education, London, UK
| | - Beth Tobiansky
- Deparatment of Psychology and Human Development, UCL Institute of Education, London, UK
| | - Kefei Wang
- Deparatment of Psychology and Human Development, UCL Institute of Education, London, UK
| | - Aaron J Cronin
- Barts Health NHS Trust, The Royal Hospital, The Royal London Hospital, London, UK
| | - Adele Johnson
- Royal National ENT and Eastman Dental Hospital, London, UK
| | | | - Anna Remington
- Deparatment of Psychology and Human Development, UCL Institute of Education, London, UK
| |
Collapse
|
22
|
Mason D, Ingham B, Birtles H, Michael C, Scarlett C, James IA, Brown T, Woodbury-Smith M, Wilson C, Finch T, Parr JR. How to improve healthcare for autistic people: A qualitative study of the views of autistic people and clinicians. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2021; 25:774-785. [PMID: 33910390 DOI: 10.1177/1362361321993709] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
LAY ABSTRACT Research has shown that on average, autistic people are more likely to die earlier than non-autistic people, and barriers can stop autistic people accessing healthcare. We carried out a study where we interviewed healthcare professionals (including doctors and nurses), and held discussion groups of autistic people. Our results highlighted several key points: seeing the same professional is important for autistic people and clinicians; both clinicians and autistic people think making adjustments to healthcare is important (and often possible); autistic people process information in a different way and so may need extra support in appointments; and that clinicians are often constrained by time pressures or targets.
Collapse
Affiliation(s)
| | - Barry Ingham
- Newcastle University, UK.,Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, UK
| | | | - Cos Michael
- Independent Autistic Consultant, Norwich, UK
| | | | - Ian A James
- Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, UK
| | - Toni Brown
- Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, UK
| | - Marc Woodbury-Smith
- Newcastle University, UK.,Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, UK
| | | | | | - Jeremy R Parr
- Newcastle University, UK.,Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, UK
| |
Collapse
|
23
|
A Systematic Review of Healthcare Professionals’ Knowledge, Self-Efficacy and Attitudes Towards Working with Autistic People. REVIEW JOURNAL OF AUTISM AND DEVELOPMENTAL DISORDERS 2021. [DOI: 10.1007/s40489-021-00263-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AbstractHealthcare professionals play a vital role in identifying and supporting autistic people. This study systematically reviewed empirical research examining healthcare professionals’ knowledge, self-efficacy and attitudes towards working with autistic people. Thirty-five studies were included. The included studies sampled a range of countries and professional backgrounds. A modified quality assessment tool found the quality of the included studies was moderately good. Narrative synthesis indicated that healthcare professionals report only moderate levels of autism knowledge and self-efficacy, and often lack training. Variation within and between countries and professional background was not explained by demographic factors. The reviewed evidence suggests health professionals’ limited knowledge and self-efficacy in working with autistic people is a challenge to the provision of healthcare for autistic individuals.
Collapse
|
24
|
Driver B, Chester V. The presentation, recognition and diagnosis of autism in women and girls. ADVANCES IN AUTISM 2021. [DOI: 10.1108/aia-12-2019-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Autistic women and girls have received comparatively less attention within clinical practice and research. Research suggests women tend to be diagnosed later than men, and are more likely to experience misdiagnosis.
Design/methodology/approach
This paper aims to report a narrative literature review that examines research on the presentation, recognition, and diagnosis of autistic women and girls.
Findings
Findings suggest that autistic females present differently to males and highlight low recognition of the female presentation of autism among the general public, in social spheres, educational, clinical and forensic settings. This lack of recognition appears to affect the likelihood of females being referred for diagnosis, the reliability of diagnostic assessments and subsequent access to support.
Originality/value
Recommendations for clinical practice focus on initiatives to increase awareness of the female presentation of autism, improving the diagnostic process for females, increasing female representation within autism training and for future research to support these goals.
Collapse
|
25
|
Crane L, Hearst C, Ashworth M, Davies J, Hill EL. Supporting Newly Identified or Diagnosed Autistic Adults: An Initial Evaluation of an Autistic-Led Programme. J Autism Dev Disord 2021; 51:892-905. [PMID: 32266684 PMCID: PMC7954714 DOI: 10.1007/s10803-020-04486-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sixteen adults (diagnosed or self-identified as autistic) participated in one of two iterations of a ten-week autistic-led programme, aimed at helping autistic adults learn more about autism within a peer group context. Motivations for taking part in the programme included a desire for: (1) exploration of autism; (2) empowerment; and (3) the development of practical strategies and coping mechanisms. Interviews were conducted upon completion of the programme and again 6 months later. Using thematic analysis, three themes were identified: (1) appreciation of the autistic-led nature of the programme; (2) unity in diversity; and (3) developing a positive, practical outlook on autism. These promising initial results highlight the value of autistic-led peer support for those recently diagnosed/identified as autistic.
Collapse
Affiliation(s)
- Laura Crane
- Centre for Research in Autism and Education (CRAE), UCL Institute of Education, University College London, 55-59 Gordon Square, London, WC1H 0NU, UK.
- Department of Psychology, Goldsmiths, University of London, London, UK.
| | | | - Maria Ashworth
- Centre for Research in Autism and Education (CRAE), UCL Institute of Education, University College London, 55-59 Gordon Square, London, WC1H 0NU, UK
| | - Jade Davies
- Centre for Research in Autism and Education (CRAE), UCL Institute of Education, University College London, 55-59 Gordon Square, London, WC1H 0NU, UK
| | - Elisabeth L Hill
- Department of Psychology, Goldsmiths, University of London, London, UK
| |
Collapse
|
26
|
Maddox BB, Crabbe S, Beidas RS, Brookman-Frazee L, Cannuscio CC, Miller JS, Nicolaidis C, Mandell DS. "I wouldn't know where to start": Perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2019; 24:919-930. [PMID: 31674198 DOI: 10.1177/1362361319882227] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
LAY ABSTRACT Most autistic adults struggle with mental health problems, such as anxiety and depression. However, they often have trouble finding effective mental health treatment in their community. The goal of this study was to identify ways to improve community mental health services for autistic adults. We interviewed 22 autistic adults with mental healthcare experience, 44 community mental health clinicians (outpatient therapists, case managers, and intake coordinators), and 11 community mental health agency leaders in the United States. Our participants identified a variety of barriers to providing quality mental healthcare to autistic adults. Across all three groups, most of the reported barriers involved clinicians' limited knowledge, lack of experience, poor competence, and low confidence working with autistic adults. All three groups also discussed the disconnect between the community mental health and developmental disabilities systems and the need to improve communication between these two systems. Further efforts are needed to train clinicians and provide follow-up consultation to work more effectively with autistic adults. A common suggestion from all three groups was to include autistic adults in creating and delivering the clinician training. The autistic participants provided concrete recommendations for clinicians, such as consider sensory issues, slow the pace, incorporate special interests, use direct language, and set clear expectations. Our findings also highlight a need for community education about co-occurring psychiatric conditions with autism and available treatments, in order to increase awareness about treatment options.
Collapse
Affiliation(s)
- Brenna B Maddox
- University of Pennsylvania, USA.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), USA
| | | | - Rinad S Beidas
- University of Pennsylvania, USA.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), USA
| | - Lauren Brookman-Frazee
- University of California, San Diego, USA.,Child and Adolescent Services Research Center, USA.,Rady Children's Hospital, USA
| | | | - Judith S Miller
- University of Pennsylvania, USA.,Children's Hospital of Philadelphia, USA
| | | | | |
Collapse
|