Disparities in Service Use Among Children With Autism: A Systematic Review

Leveraging Feedback From Families of Children With Autism to Create Digital Support for Service Navigation: Descriptive Study

BACKGROUND

It is difficult for families to navigate and access services for their children with autism. Barriers to service access are compounded among families from low-resourced backgrounds.

OBJECTIVE

The purpose of our study was to explore the development of an app to facilitate access to services among families of children with autism from low-resourced backgrounds. Our specific aims were to explore feedback from an advisory board about the app and to explore feedback from navigators about the app.

METHODS

Via a multistage codevelopment process, we elicited feedback from 5 key parties: the research team, a community organization, the app development team, the advisory board, and family navigators. Collectively, 36 individuals provided feedback about the development of the app via individual interviews, focus groups, observations, and surveys. The key features of the app included a dashboard showing the service needs of the family and related resources, a messaging feature between the family, the navigator, and the supervisor, and a fidelity checklist and evaluation feature.

RESULTS

The advisory board provided feedback about the app to increase its user-friendliness, include the ability to develop an action plan, improve the identification of needed services, and add information about service providers. Navigators suggested that the app should connect navigators to one another, have a clearer purpose for the notes section, and reflect an easier log-in process. Navigators also wanted training to role-play using the app. After participating in a role play using the app, navigators reported significantly more satisfaction with the app and greater usefulness (P<.001).

CONCLUSIONS

Our work sheds light on the importance of eliciting feedback from end users, especially users who are often overlooked by the research community and app developers. Further, it is important to elicit feedback in multiple ways to improve the app.

Exploring the experiences of ableism among Asian children and youth with disabilities and their families: a systematic review of qualitative studies

PURPOSE

Asian children and youth with disabilities often experience multiple barriers, stigmas and discrimination within and outside their families; yet less is understood about their lived experiences. This systematic review explored the experiences of ableism among Asian children and youth with disabilities and their families.

METHODS

We conducted a systematic review of qualitative studies and a qualitative meta-synthesis. We searched six databases including Ovid Medline, Embase, PsychInfo, Healthstar, Web of Science, and Scopus.

RESULTS

Forty-two articles met our inclusion criteria involving 17 countries and regions over a 22-year period. The findings were synthesized into four themes: (1) individual- and family-level ableism (i.e., stigma, fears, concerns, stress and anxieties, physical abuse, bullying, reduced engagement in community activities); (2) institutional-level ableism (i.e., barriers to accessing and navigating supports, ableist attitudes among service providers, unavailable services); (3) societal-level ableism (i.e., cultural and religious stigma, social rejection, discrimination, environmental and policy barriers); and (4) coping strategies (i.e., self-care activities, supports from family, friends and people with similar conditions, religious beliefs).

CONCLUSIONS

Our results highlight the ableist experiences that Asian children and youth with disabilities and their caregivers often encounter and the strong need for further supports to address ableism using culturally responsive strategies.

Short report: Examining race, ethnicity, sex, and gender among autistic youth and their educators who participated in school-based research

LAY ABSTRACT

Schools are the main provider of behavioral health services in the United States (US). Conducting research in schools may help increase access for autistic youth, but there is limited research about who participates in school-based autism research. The researchers examined data spanning 14 years of participation in school-based autism research. All data were collected in the US. Researchers found that in this sample, more than half of the youth identified as racial/ethnic minoritized (REM) youth. However, demographics of sampled youth were significantly different than expected, based on publicly available school-based population demographics. More youth identified as White non-Hispanic than would be expected in those schools. Majority of the sampled educators also identified as White non-Hispanic. High percentages of autistic REM youth suggest school-based autism research may be an effective way of providing services to more diverse populations. However, sampled schools were also not representative of a US national sample, with sampled schools having fewer White non-Hispanic youth than would be expected from US national statistics. Complexity around representation of schools sampled and demographics of service environments suggests a need for more research.

"Capable of much more": The effects of vocational training on caregiver expectations for neurodivergent dependents in Thailand

Neurodivergence encompasses a spectrum of natural variations in neurological development, including autism, ADHD, and other expressions of cognitive diversity. Caregiver experiences while supporting their neurodivergent dependents critically influence the quality of life outcomes for neurodivergent dependents across life stages, including during the search for work. However, research on caregiver experiences during this stage remains scarce, especially within lesser studied developing contexts like Thailand. This study explored perspectives of Thai caregivers preparing neurodivergent dependents for employment through a focus group (n = 10) of pre-vocational training caregivers and interviews (n = 13) with post-training caregivers. Analysis revealed significant sociocultural factors introducing stigma that affected acceptance, diagnosis, interventions, and policy support. Both groups reported systemic barriers, doubts about future independence, and hopes to increase advocacy and inclusive attitudes. However, caregivers whose dependents had received the training showed marked shifts in their expectations for their dependents' success. Tailored vocational preparation helping dependents exhibit strengths may transform societal views on neurodiversity from deficiency to natural diversity and enable more meaningful, sustainable futures. These insights elucidate caregiver challenges and aspirations, which can better inform supportive research and interventions in Thailand and other non-Western locales.

The positive impact of identity-affirming mental health treatment for neurodivergent individuals

Introduction

The medical and social definitions of neurodivergence have become a common topic of discussion in recent years, and the ways that we define, measure and report on conditions within the neurodivergent umbrella are changing. The objective of this study was to analyze differences in mental health symptom presentation at intake and compare treatment outcomes among three groups: clients with an affirming neurodivergent diagnosis, clients without an affirming diagnosis, and neurotypical clients.

Methods

Data were collected at intake and discharge. Clients self-reported neurodivergent identity, neurodivergent diagnoses, as well as the severity of depression symptoms, anxiety symptoms and self-harm frequency. One-way multivariate analysis of variance tests were run to assess differences in mental health symptoms at intake and discharge based on neurodivergent identity and corresponding diagnosis. When MANOVAs indicated significant differences, follow-up univariate one-way ANOVAs were conducted for each dependent variable.

Results

Neurodivergent clients reported significantly worse mental health symptoms at intake than neurotypical clients, regardless of diagnosis status. Additionally, clients who identified as neurodivergent but did not report an affirming medical diagnosis reported significantly worse mental health symptoms than those who did report an affirming medical diagnosis. By discharge from IOP treatment, no significant differences were found in symptom change scores between neurodivergent and neurotypical individuals, or neurodivergent individuals with an affirming diagnosis and those without.

Discussion

These findings highlight the importance of acknowledging client identity as a key component of mental health treatment. The act of validating symptoms and experiences, allowing accommodations when requested, and exploring identity formation regardless of diagnosis, allowed all clients who identified as neurodivergent to benefit from treatment.

"There is No Help:" Caregiver Perspectives on Service Needs for Adolescents and Adults with Profound Autism

The underrepresentation of individuals with profound autism (who require 24/7 access to care) in autism research has resulted in limited knowledge about their service needs and a lack of evidence-based practices tailored to those needs. This study explored caregiver perspectives on service needs, barriers to accessing care, and treatment priorities to guide treatment development and improvement of service delivery. A sequential mixed-methods design integrated quantitative survey data (n = 423; Mage = 18.89 years; 26.7% female) with qualitative interviews (n = 20) with caregivers of adolescents and adults with profound autism. Quantitative findings indicated regular socialization opportunities were the most frequently endorsed unmet service need (60.3% of caregivers), followed by primary health care with autism-trained staff (59.3%), social skills instruction (55.8%), life skills instruction (51.3%), and behavioral support (47.3%). Higher likelihood of needing social activity groups was associated with elevated emotional reactivity, higher language level, minoritized ethnicity, and lower household income. Greater need for specialized primary health care was associated with lower income, while the need for social and life skills instruction was associated with increased age and elevated dysphoria. Qualitative analysis identified 10 themes that converged and expanded quantitative findings by highlighting a pervasive shortage of individualized, goal-oriented services, common barriers to care, and the priority of developing centralized treatment settings that coordinate care throughout adulthood. This study identified pressing service needs for adolescents and adults with profound autism in the United States. These insights are crucial for improving the accessibility and quality of clinical care.

Integration of Family Navigation into ECHO Autism for Pediatric Primary Care in Underserved Communities

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.

Scope-of-Practice Expansions Associated with Reduced Racial Disparities in Pediatric Mental Health Care

To examine the association between scope-of-practice (SoP) regulations and racial disparities in pediatric mental health services. We used the National Survey of Children's Health (2016-2020; n = 33,790) to examine racial disparities in unmet mental health care needs and receipt of mental health medication between states with and without SoP expansions for psychologists and nurse practitioners (NP). Our primary outcomes were (1) unmet mental health care needs and (2) receipt of mental health medication. We examined heterogeneous treatment effects of SoP expansion on the outcomes using logistic regression with interaction terms between SoP expansion and race/ethnicity. We estimated population-level racial disparities for both outcomes stratified by SoP expansion to identify differences in racial disparities. The psychologist SoP expansion-associated reduction in unmet need was 15.8 percentage-points (CI= -25.3, -6.2) larger for Other-race children than for White children. The psychologist SoP expansion-associated increase in medication was 5.1%-points (CI=. 0.8, 9.4) larger for Black children and 5.6%-points (CI = 0.5, 10.8) for Other-race children. No differences were found for NP SoP expansion. Racial disparities in both outcomes were lower in psychologist SoP expansion states but varied in NP SoP states. Expanded SoP was generally associated with lower racial disparities in pediatric mental health care access.

The Role of Implementation Climate in Moderating Educator Use of Evidence-Based Practices and Outcomes for Autistic Students

Ensuring effective use of evidence-based practice (EBP) for autism in schools is imperative due to the significantly increasing number of autistic students receiving school services each year. High-quality EBP use has proven challenging in schools. Research indicates implementation climate, or how EBP are supported, rewarded, and valued, and EBP resources are related to successful implementation. However, limited understanding of system-level contextual factors that impact EBP implementation for school-based providers makes development of appropriate implementation supports challenging. Understanding these factors is crucial for selecting and tailoring implementation strategies to support EBP scale up. In this observational study, California school-based providers (n = 1084) completed surveys related to implementation climate, leadership, autism experience and EBP implementation (use, competence, knowledge). Student outcomes included state level academic and behavioral indicators. Using an implementation science framework (Aarons et al., in Administration and Policy in Mental Health and Mental Health Services Research 38:4-23, 2011) and multilevel modeling, we examined the relationship between EBP Implementation and student outcomes and the moderation effects of provider and district level factors. Higher implementation climate predicted better EBP implementation outcomes, and proved more impactful when provider hands-on autism experience was low. Greater EBP resources predicted a higher percentage of students who met math standards only when district poverty level was high. Our findings suggested moderating effects on EBP implementation from both provider and system level factors. Implementation climate and resources may be especially key in addressing equity issues related to high poverty schools in which teachers often have less autism experience.

Predictive Analysis of Parent Activation and Autism

We examined parent activation in families with autistic children over time. Activation is one's belief, knowledge, and persistence in obtaining and managing one's care (e.g., patient activation) and others (e.g., parent activation) and is associated with better outcomes. Four aims were examined: the associations between baseline parent activation and follow up treatment/outcome, between changes in activation and changes in treatment/outcome, differences in activation and treatment/outcome across demographic groups (e.g., gender, race, ethnicity, and income) and comparison of results using three different assessment approaches of parent activation, the Guttman scale (standard approach) and two factor subscales (Yu et al., in J Autism Dev Disord 53:110-120, 2023). The first factor tapped into behaviors aligned with highly active, assertive parental actions (Factor 1: Activated). The second tapped into behaviors representative of uncertainty, passivity, being overwhelmed, with growing awareness of the need for activation (Factor 2: Passive). Findings varied with assessment methods applied. The two subscales assessment approach produced the strongest effect sizes. Baseline activation was related to improved child outcomes at follow-up for Factor 1: Activated and to poorer child outcomes at follow-up for Factor 2: Passive. Changes in activation were unrelated to changes in treatment/outcomes. Outcomes differed based on the activation assessment approach used. Against expectations, activation remained the same over time. Further, no differences in outcomes were observed based on race, ethnicity, or family income. The results suggest that parent activation may behave differently than patient activation based on prior studies. More research is warranted on activation of parents of autistic children.

Reducing Depressive Symptoms Among Latina Mothers of Autistic Children: A Randomized Controlled Trial

This study examines the intervention effect of a culturally tailored parent education program in reducing depressive symptoms among Latina mothers of autistic children. In this two-site randomized waitlist-control study (n = 109 mother-child dyads), a peer-to-peer mentoring (promotora) model was used to deliver an intervention that was designed to increase mothers' self-efficacy and use of evidence-based strategies. We assessed mothers' depressive symptom (CES-D) scores at three time points and used linear mixed models to determine whether their scores significantly changed from baseline to postintervention (Time 2) and at 4 months postintervention (Time 3). Results show that mothers in the intervention group reported a significant decrease in mean depressive symptom scores at Time 2 and that the effect was maintained at Time 3 with intermediate to medium effect sizes. There were no differences in results across sites. Findings suggest that Parents Taking Action, a culturally tailored intervention led by peer mentors, showed a significant effect both immediately after the intervention and 4 months postintervention in reducing depressive symptoms among Latina mothers of autistic children.

Race and Ethnicity Reporting in Occupational Therapy Research Among Autistic Youth

Historically marginalized racial and ethnic groups are underrepresented in autism research broadly; however, patterns of inclusion in occupational therapy research are unknown.In this secondary data analysis, we examined race and ethnicity reporting across articles included in a systematic review of evidence related to occupational therapy practice with autistic individuals <18 years (2013-2021).Two team members reached >90% interrater coding agreement in race and ethnicity reporting across articles in ADLs/IADLs, education/work, play, sleep, and social participation in clinics, homes/communities, and schools.Intervention outcomes of ADL/IADLs (66.7%) and play (66.7%) had low rates of reporting, while social participation in schools (100%) and education/work (100%) had higher rates of reporting. Sample diversity was greatest among research in schools and most limited in clinic-based settings.Systemic racism that limits individuals' participation in occupational therapy research perpetuates racial and ethnic health inequities among autistic children and adolescents.

Child Age at Time of First Maternal Concern and Time to Services Among Children with Autism Spectrum Disorder

OBJECTIVE

Early treatment of autism spectrum disorder (ASD) can improve developmental outcomes. Children with ASD from minority families often receive services later. We explored factors related to child's age at time of mother's first concerns about child's development and subsequent time to service initiation among children with ASD.

METHODS

Analysis included 759 preschool-age children classified with ASD based on comprehensive evaluations. Factors associated with retrospectively reported child age at time of first maternal concern and subsequent time to service initiation were investigated using multiple linear regression and Cox proportional hazards.

RESULTS

Earlier maternal concern was associated with multiparity, ≥1 child chronic condition, externalizing behaviors, and younger gestational age, but not race/ethnicity. Time to service initiation was longer for children of non-Latino Black or other than Black or White race and higher developmental level and shorter for children with ≥1 chronic condition and older child age at first maternal concern.

CONCLUSION

Parity, gestational age, and child health and behavior were associated with child age at first maternal concern. Knowledge of child development in multiparous mothers may allow them to recognize potential concerns earlier, suggesting that first time parents may benefit from enhanced education about normal development. Race/ethnicity was not associated with child's age when mothers recognized potential developmental problems; hence, it is unlikely that awareness of ASD symptoms causes racial/ethnic disparities in initiation of services. Delays in time to service initiation among children from racial/ethnic minority groups highlight the need to improve their access to services as soon as developmental concerns are recognized.

Partnering With a Purpose: Promoting Equity and Justice for Black Children With Autism Spectrum Disorder

OBJECTIVE

Black children with autism and their families face disparities within clinical care and services, leading to inequitable health outcomes. However, there is limited research centering the voices of the Black autism community in understanding how to address these inequities. In this study, researchers explored the perspectives of caregivers of Black children with autism regarding barriers to equitable care and recommendations for improved services.

METHODS

Community leaders from an autism advocacy group and researchers from a large academic medical center partnered to conduct a Group Level Assessment with 31 Black families of children with autism. During a three-hour research event, participants discussed their experiences within community, school, and clinical services, collectively coded and interpreted the data, and generated action steps to improve services.

RESULTS

The findings revealed 6 areas of need regarding the services Black children with autism and their caregivers receive. Black caregivers recommended that systems of care improve access to culturally responsive care, integrate caregiver priorities within their care, and engage in collaborative decision-making with caregivers. Providers should also equip caregivers with an accessible roadmap for navigating their child's services and connect them to care management professionals and resources for mental health support.

CONCLUSION

The findings of this study address a critical gap in the literature by partnering with the Black autism community to identify solutions to address their needs; these recommendations can be used as a foundation for service providers to reduce disparities and improve outcomes for Black children with autism and their families.

Social Determinants in COVID-19 Experiences of Children With Disabilities Receiving School-Based Services in Chicago: Mixed-Methods Study of Parent/Guardian Perspectives

OBJECTIVE

To identify the impact of social determinants on the experiences of children with disabilities and their families during the COVID-19 pandemic from the perspective of parents/guardians.

METHODS

A mixed-methods study engaged parents/guardians of children with Individualized Education Programs (IEPs) in July to August 2021 at a developmental/behavioral pediatrics clinic in 1 urban academic medical center. All parents/guardians completed study-specific surveys on experiences and impact of COVID-19. A subset completed semi-structured interviews. Analysis included descriptive statistics and Fisher exact tests for survey questions and thematic analysis to code interviews and identify themes. Results were corroborated by experts in developmental/behavioral pediatrics and special education.

RESULTS

Participants included 24 parents/guardians representing 27 children (mean = 7.37 years). A majority attended public school (78%) and identified as non-White (78%). Most commonly, the children's disabilities were autism (52%), attention-deficit hyperactivity disorder (37%), and speech/language impairment (33%). The services received by children most commonly were speech/language (89%) and physical/occupational (70%) therapies. Five themes emerged about the impact of social determinants on experiences during COVID-19 related to: adapting to disruption of routines, attendance/engagement in learning, interruption of IEP services, support for children and families, and challenges with technology.

CONCLUSION

Social determinants, such as housing, income, insurance, and quality of education, affected the experiences of families and their ability to adapt to the needs of children with disabilities in the setting of COVID-19 pandemic-related changes.

Experiences of racism and racial disparities in health care among children and youth with autism and their caregivers: a systematic review

PURPOSE

Although the health benefits of early diagnosis and therapeutic approaches for children and youth with autism spectrum disorder (ASD), racial disparities persist. This systematic review explored the experiences of racism and racial disparities in health care among children and youth with ASD and their caregivers.

METHODS

We conducted a systematic review, drawing on six international databases. Two reviewers screened titles, abstracts, and full texts. Thirty-seven studies met our inclusion criteria and we applied a narrative synthesis to develop themes.

RESULTS

Four themes were identified: (1) experiences and aspects of racism and racial disparities (i.e., language and cultural barriers, poor quality health care interactions, stereotypes and discrimination, family and community stigma, and indirect barriers); (2) racial disparities in health care (i.e., screening and referral, diagnosis, health care services, and care coordination and medication); (3) facilitators to accessing health care services; and (4) recommendations from caregivers.

CONCLUSIONS

This review highlights the extensive racial disparities experienced by children with autism. More research is needed to explore youth's perspectives on racism in addition to exploring potential interventions to address racial disparities and improve health equity for youth with ASD.

ECHO Autism Washington: Autism Diagnostic Evaluations in Primary Care

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.

A Systematic Review of Recruiting and Retaining Sociodemographically Diverse Families in Neurodevelopmental Research Studies

Underrepresentation of socioeconomically, culturally, and/or linguistically diverse (SCLD) children with neurodevelopmental disorders (NDD) and their families has become a focal point for researchers. This systematic review aimed to identify researchers' strategies for recruiting and retaining SCLD families of children with NDD, published between 1993 and 2018. One hundred twenty-six articles were included, and study samples were categorized as "High SCLD" and "Low SCLD". Chi-square tests of independence were used to determine associations between sample composition (i.e., High/Low SCLD sample) and study characteristics reported. Significant associations were found between sample composition and studies that explicitly stated intention to recruit SCLD families, χ2(1) = 12.70, p < .001, Phi = 0.38 (moderate); and for studies that reported the following participant characteristics: language, χ2(1) = 29.58, p < .001, Phi = 0.48 (moderate-to-large); and race/ethnicity + SES + language, χ2(1) = 19.26, p <. 001, Phi = 0.39 (moderate). However, associations were not found between recruitment and retention approaches and whether studies included High SCLD or Low SCLD samples. Further study of NDD researchers' recruitment and retention approaches that successfully include SCLD families is needed.

Exploring Racial and Ethnic Differences in Parent-Reported Strengths in Children with Autism Spectrum Disorder

BACKGROUND

Several studies have demonstrated racial/ethnic differences in parental concerns in children with autism spectrum disorder (ASD). However, no studies have investigated racial/ethnic differences in parent-reported strengths. The purpose of this study was to explore racial/ethnic differences in parent-reported strengths in children with ASD.

DESIGN AND METHODS

This was a retrospective cross-sectional study investigating the relationship between parent-reported strengths and race/ethnicity at the time of an ASD diagnosis. Parent-reported strengths were qualitatively clustered into themes, and theme frequencies were quantitatively examined for relationships to race/ethnicity.

RESULTS

Parents of Caucasian children reported a mean of 5.00 (SD = 2.17) total strengths compared to 3.75 (SD = 2.32) among Hispanic/Latinx children, 3.36 (SD = 1.43) among Asian/PI children, and 3.91 (SD = 2.05) among children from other races/ethnicities. Bivariate linear regression analyses indicated that Asian/PI, Hispanic, and other child race/ethnicity, compared to Caucasian child race/ethnicity, were associated with significantly fewer parent-reported total strengths. Asian/PI and Hispanic child race/ethnicity were associated with significantly fewer personality strengths, while maternal education was associated with a greater number of personality strengths.

CONCLUSION

This study found racial and ethnic differences in parent-reported strengths in children with ASD. Further, higher levels of maternal education influenced total, personality, and behavioral strengths. Receipt of a greater number of child services was also associated with a greater number of behavioral strengths.

Unpacking the prevalence: A warning against overstating the recently narrowed gap for Black autistic youth

Recent findings from the Centers for Disease Control and Prevention's (CDC) Autism and Developmental Disabilities Monitoring (ADDM) Network's 2020 prevalence report indicate that disparities in autism diagnoses between Black and White youth have narrowed, reflecting improved screening, awareness, and access to services (Maenner et al., 2023. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 72, 1-14.). Claims of reducing disparities beyond prevalence rates, however, are not fully supported, as indicated by the reality that Black youth whose screenings indicate autistic traits are still not being referred for full evaluation or early intervention services at the same rate as their White peers (Major et al., 2020. Autism, 24, 1629-1638; Smith et al., 2020. Pediatrics, 145, S35-S46.). Black 8-year-olds identified as autistic still experience disparate educational placements (Waitoller et al., 2010. The Journal of Special Education. 44, 29-49.) where services may not be autism-specific or have Individual Education Plan goals only focused on "behavior problems" (Severini et al., 2018. Journal of Autism and Developmental Disorders, 48, 3261-3272.), are served in the most restrictive environments (Skiba et al., 2006. Exceptional Children, 72, 411-424.) and lack consistent augmentative and alternative communication support (Pope et al., 2022. American Journal of Speech-Language Pathology, 31, 2159-2174.). Additionally, ADMM researchers report consistent disparities in the identification of co-occurring intellectual disability where Black autistic children have significantly more co-occurrences than White autistic children. The purpose of this commentary is to first examine the assertion that the narrowed gap indicates, "…improved…access to services among historically underserved groups," (p. 9) (Maenner et al., 2023. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 72, 1-14.). We will then recommend strategies to address the ongoing disparities.

Field Testing the Family Behavior Support Mobile Application (FBSApp) During a Global Pandemic

We developed and tested an evidence-based mobile application designed to support families in using functional assessment-based intervention strategies with their young children with disabilities and challenging behaviors in home settings. Five families participated in the study. We utilized a multiple-probe across participants design to examine the effects of the FBSApp on parents' use of intervention strategies and childrens' use of challenging behaviors and replacement behaviors. We adapted our procedures to include individualized coaching to provide meaningful and effective support after the onset of the COVID-19 pandemic. A functional relation was not identified between access to FBSApp and caregiver use of strategies; however, the addition of coaching did lead to increased strategy use for two of four caregivers. A functional relation was identified between the use of the FBSApp plus coaching and CB. Families reported the app and coaching procedures favorably. We found that responsive, family-centered research CAN be conducted in spite of significant history events, and that mobile apps and virtual meeting platforms can be an accessible and efficient method for supporting families. The use of single case design allowed for flexible, yet methodologically sound procedures. More work is needed examining effective and efficient virtual supports for families.

Differential Performance of Social Communication Questionnaire Items in African American/Black vs. White Children

Screening for autism spectrum disorder (ASD) is an essential early step in the identification process and inaccurate screening may lead to significant delays in the onset of treatment. Past research has highlighted discrepancies in the performance of ASD screening tools such as the Social Communication Questionnaire (SCQ) among certain racial and ethnic groups. The current study explored the functioning of the SCQ among African American/Black and White respondents based on item level performance on the measure. Differential Item Functioning (DIF) analyses showed that 16 (41%) items of the SCQ functioned differently for African American/Black respondents when compared to White respondents. Implications, such as the potential for delayed diagnosis and treatment, and the influence on downstream outcomes, are discussed.

A Mixed-methods Examination of Culturally Responsive Adaptation to an Evidence-based Parent-mediated Intervention Implemented for Autistic Children

Parent-mediated interventions (PMIs) are considered an evidence-based practice for fostering social communication skills in young autistic children and for promoting parent responsivity and empowerment, yet barriers to caregiver engagement are evident when PMIs are implemented within historically underserved community settings. Issues of caregiver engagement can reflect a lack of fit between PMIs and the needs of diverse families. We used a mixed methods approach to examine barriers to participating in an evidence-based PMI, Project ImPACT (Ingersoll & Dvortcsak, 2019), within an outpatient setting, as well as strategies that clinicians reported using to deliver and adapt Project ImPACT for minoritized families. Participants included 134 caregivers of a child 13 to 48 months with autism or other social communication differences and six clinicians delivering Project ImPACT. Findings suggest that caregivers experience barriers to participating in Project ImPACT and that these barriers are associated with caregivers' ability to complete the program. Although quantitative findings indicate that adaptation to Project ImPACT did not differ by caregiver and child background, qualitative findings highlighted that clinicians attempt to deliver Project ImPACT to respond to the needs of families from minoritized backgrounds by actively considering the family's culture, psychosocial experiences, goals, and specific barriers. Further, both qualitative and quantitative findings suggest that culturally responsive care and adaptations may support caregiver engagement, including rapport, trust, buy-in, and attendance. Approaches to center cultural alongside contextual/psychosocial considerations within family-centered care in the implementation of PMIs are also highlighted.

Exploring the Perspectives of Parents of Individuals with Autism from Low-Resourced Communities to Inform Family Navigator Programs

Family navigator programs (i.e., programs to train family navigators) are becoming increasingly common among families of children with autism. Family navigators (i.e., individuals who help families access evaluations and/or services) may be parents of children with autism themselves or health professionals. Extant research has shown that family navigators can help families receive timely diagnostic evaluations and initial services. Yet, the development of family navigator programs is unclear; by exploring the input of families of children with autism, such programs can be responsive to family needs. In this study, we extend the extent literature by exploring the lived experiences of 12 parents of autistic children from low-resourced communities to inform the development of a family navigator program. Findings demonstrated that navigator programs need to prepare navigators to address barriers such as limited knowledge and difficulty accepting an autism diagnosis. Navigator programs should teach navigators to use strategies with families including educating families about services and connecting families with peer support. Program content should reflect direct services, government services, and advocacy strategies. Notably, for true improvements to service access for all autistic children, systemic changes are also needed in the service delivery systems. Implications are discussed.

Screening for Autism: A Review of the Current State, Ongoing Challenges, and Novel Approaches on the Horizon

Screening for autism is recommended in pediatric primary care. However, the median age of autism spectrum disorder (ASD) diagnosis is substantially higher than the age at which autism can reliably be identified, suggesting room for improvements in autism recognition at young ages, especially for children from minoritized racial and ethnic groups, low-income families, and families who prefer a language other than English. Novel approaches are being developed to utilize new technologies in aiding in autism recognition. However, attention to equity is needed to minimize bias. Additional research on the benefits and potential harms of universal autism screening is needed. The authors provide suggestions for pediatricians who are considering implementing autism-screening programs.

Comparative effects of mindfulness-based stress reduction and psychoeducational support on parenting stress in families of autistic preschoolers

LAY ABSTRACT

Parents of autistic children often experience high levels of parenting stress, which can have negative mental and physical effects on both the parent and child. This study tested the efficacy of mindfulness-based stress reduction in reducing parenting stress in parents of preschool-aged autistic children compared to a psychoeducation and support intervention. We assessed parenting stress before and after the interventions and at 6- and 12-month follow-up. Both interventions significantly decreased parenting stress, but mindfulness-based stress reduction reduced stress more than did psychoeducation and support, with the strongest effect observed 1 year later. This suggests that the stress-reducing benefits of mindfulness-based stress reduction persist and may increase over time.

Workforce perspective on racial and ethnic equity in early childhood autism evaluation and treatment: "The cornerstone of everything we do"

LAY ABSTRACT

Black and non-White Latinx children tend to receive autism diagnoses later in life and with a higher degree of impairment than White children. The purpose of this study was to learn what is currently helping as well as preventing Black and non-White Latinx children from getting access to autism evaluation and services. We held virtual interviews with 26 experts who work with autistic children and their families, including clinical providers, researchers, advocates, and policymakers/government representatives. From these interviews, we identified four themes that have an impact on equity in autism services: (1) who makes up the workforce, (2) workforce capacity and accessibility, (3) workforce payment structure, and (4) changes due to the COVID-19 pandemic. These findings show the need for improved workforce diversity, autism-specific education, payment structures, and additional support for workforce members to avoid burnout. To make childhood autism services more equitable, diversity in recruitment across training levels, cultural awareness, increased autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow professionals in the field to better meet the needs of children and families from Black and non-White Latinx communities and achieve equity in early childhood autism services.

Assessing Growth of BACB Certificants (1999-2019)

Geographic distribution patterns of board certified behavior analysts may be useful in analyzing the growth of the field. First, we present an international snapshot of Behavior Analyst Certification Board (BACB) certificants, then analyze relative growth rates between countries from 1999 to 2019. This is followed by an in depth review of certificant distribution patterns in the United States and Canada, as well as the ratios of experienced behavior analysts to new certificants. These data highlight regions with a potential deficit of qualified supervisors. There are factors that influence different dispersal patterns, and without drilling deeper into the data we may be unable to effectively identify or influence them in order meet the specific needs of a geographic region.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-023-00370-5.

Mortality risk among Autistic children and young people: A nationwide birth cohort study

LAY ABSTRACT

Existing literature indicates that Autistic people have shorter life expectancy, but little is known about the mortality risk among Autistic children and young people (0-24 years). We used a 15-year nationwide birth cohort study to estimate the mortality risk among Autistic children and young people in Aotearoa/New Zealand. The study included 895,707 children and 11,919 (1.4%) were Autistic. We found that autism was associated with a significantly higher mortality risk compared to the non-Autistic population. In addition, we found that this risk was significantly higher among females compared to males and for those with a co-occurring intellectual disability. Increased efforts are required to better meet the health needs of this population.

Sociodemographic Disparities in Educational Services in Children who are Deaf or Hard of Hearing

OBJECTIVE

Examine the association between sociodemographic factors and Individualized Education Program (IEP) establishment.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

METHODS

Participants included deaf or hard-of-hearing children who were eligible for an IEP with "deafness" or "hard of hearing" as a primary or secondary disability. Primary outcome measures were time intervals between initial referral for services and parental consent; parental consent to determination of eligibility; and initial referral to eligibility (the sum of the previous 2 intervals). Student's t tests and linear regression were used to examine the association between sociodemographic factors and the primary outcome variables.

RESULTS

Of the 88 participants, 51 (58%) were male, 45 (51%) were from underrepresented minority (URM) groups, 35 (40%) spoke a primary language other than English, and 53 (60%) utilized public insurance. IEP establishment was significantly delayed in participants who required an English-language interpreter. Most of the delay occurred in the time between the initial referral and parental consent (mean: 115 vs 37 days, P = .02). There were also significant delays from the time of referral for services to eligibility in URM participants (mean: 159 vs 85 days, P = .04). Significant delays were also associated with Minority Status and Language within social vulnerability index percentile rankings.

CONCLUSION

This study found that IEP establishment was delayed in both URM participants and those who required an English-language interpreter. These results highlight the importance of clear communication between the school system and caregivers in the IEP establishment process, particularly with families who require an English-language interpreter or identify as URM.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

Supporting Caregivers Remotely During a Pandemic: Comparison of WHO Caregiver Skills Training Delivered Online Versus in Person in Public Health Settings in Italy

Feasibility, acceptability and effectiveness data of a virtual adaptation of the WHO Caregiver Skills Training (CST; n = 25) were compared with those of a pilot RCT of CST delivered in person (n = 43) against treatment as usual (TAU; n = 43). Virtual CST was delivered with high levels of integrity, but received lower ratings in some caregiver- and facilitator-rated acceptability and feasibility dimensions. Qualitative analysis identified both benefits (flexibility, convenience, clinical usefulness) and challenges, (technological issues, distraction from family members, emotional distance). Virtual and in-person CST improved significantly more on caregiver competence than TAU; there were no other significant effects. Potential for use of virtual CST as a clinical response in contexts where in-person delivery is not possible is discussed.

Differences Between Black and White Caregivers in the Association Between Autism Diagnostic Process Satisfaction and Service Use

BACKGROUND

Black families of children with autism spectrum disorder have less access to high quality, culturally responsive care for their children.

METHOD

We assessed satisfaction and service utilization among fifty (29%) Black caregivers and 124 (71%) White caregivers of children with autism spectrum disorder. We also examined whether race moderated the association between satisfaction and service utilization.

RESULTS

We did not identify racial differences in satisfaction or service utilization. Race moderated the association between satisfaction and total service use, F(170) = 5.29, p =.02, therapy service use, F(163) = 3.59, p =.046, and community service use, F(169) = 4.76, p =.046. For Black families, there was a positive association between satisfaction and service use. There was no association between satisfaction and service use among White families.

DISCUSSION

Satisfaction may be particularly important among Black families, who have been mistreated by the healthcare system and frequently face discrimination. Our results suggest the importance of culturally responsive care for Black families.

Assessment of Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by challenges in social interaction and communication and the presence of restricted interests and repetitive behaviors. The importance of early detection of ASD and subsequent early intervention is well documented. Efforts have been made over the years to clarify ASD diagnostic criteria and develop predictive, accurate screening tools and evidence-based, standardized diagnostic instruments to aid in the identification of ASD. In this article, we review the most recent changes in ASD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, summarize evidence-based instruments for ASD screening and diagnostic evaluations as well as the assessment of co-occurring conditions in ASD, the impact of COVID-19 on ASD assessment, and directions for future research in the field of ASD assessment.

Racial and Ethnic Disparities for Unmet Needs by Mental Health Condition: 2016 to 2021

OBJECTIVES

Racial and ethnic minority children receive less care and inferior care in the United States, but less is known about how these disparities vary by mental health conditions. We examined unmet mental health needs by condition types to identify potentially hidden racial and ethnic inequities.

METHODS

We used data from the nationally representative National Survey of Children's Health, from 2016 to 2021 (n = 172 107). Logistic regression analyses were applied to mental health conditions in aggregate and individually and adjusted for individual and household characteristics.

RESULTS

Relative to non-Hispanic white children with any mental health condition, non-Hispanic Black children had greater odds of unmet needs (adjusted odds ratio [aOR] = 1.56, 95% confidence interval [CI]: 1.18-2.05). Models disaggregated by specific mental health conditions revealed heterogeneous patterns. Specifically, relative to non-Hispanic white children, non-Hispanic Black children displayed elevated odds of unmet needs for behavioral problems (aOR = 1.41, 95% CI: 1.00-2.02), whereas Asian and Hispanic children displayed elevated odds for anxiety (aOR = 2.60, 95% CI: 1.20-4.29 and aOR = 1.41, 95% CI: 1.05-1.90, respectively).

CONCLUSIONS

Racial and ethnic minority children are disproportionately affected by unmet treatment needs. These disparities vary by individual mental health conditions and persist after controlling for socioeconomic characteristics. Results reveal clinically underserved racial and ethnic groups across different mental health conditions.

Effects of physical exercise, LEGO, and Minecraft activities on anxiety in underserved children with autism: Study design and methodological strategies

Anxiety is a common comorbidity for individuals with ASD, and there is some preliminary data about the efficacy of physical exercise to alleviate anxiety. However, we are not aware of any studies that have compared the effects of a physical exercise program on anxiety in underserved children with ASD using a randomized controlled research design. This paper describes a method to evaluate and compare the efficacy of an 8-week physical exercise intervention with a sedentary play intervention to alleviate anxiety in young children with autism spectrum disorders (ASD) from underserved backgrounds. We assessed anxiety and its physical symptoms using the parent-rated Child Behavior Checklist DSM-5 anxiety (CBCL DSM-5) subscale, the child-rated Screen for Childhood Anxiety Related Emotional Disorder (SCARED), the parent-rated Child's Sleep Habits Questionnaire (CSHQ), and salivary cortisol. We also utilized the Physical Activity Questionnaire for Older Children (PAQ-C) to assess physical activity level and identify compounds. Unique components of this study include: •Implementation of novel physical exercise and sedentary play interventions that have been designed for children with ASD.•Recruitment of predominantly underserved and non-English speaking families.

Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria

BACKGROUND AND OBJECTIVES

Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations.

METHODS

This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record.

RESULTS

Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis.

CONCLUSIONS

Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Factors Associated with Pre-Research Recruitment in Autism and Related Developmental Disorders

PURPOSE

Access to research programs and increased diversity in research enrollment may be key to improving diverse populations' health and healthcare outcomes. To facilitate research recruitment, a Research Registry ("Registry"), a pre-recruitment database, was developed at an urban tertiary Autism Center ("Autism Center"). In this study, we examined whether disparities in research participation occur in the pre-research recruitment (pre-recruitment) stage.

METHODS

We compared demographic factors of patients seen at the Autism Center (but not enrolled in the Registry) vs. patients enrolled in the Registry. We also examined whether demographic factors differ among the Registry participants who were enrolled in the Registry by signing an informed consent form (ICF) vs. by returning a research interest form (RIF).

RESULTS

A total of 18,522 patients (including 1092 patients in the Registry with 403 patients via ICF and 689 patients via RIF) were included in this study. English as the primary language, White race, Non-Hispanic ethnicity, and younger age at their first clinic encounter were associated with the Registry. In the Registry sample, the RIF group had a higher proportion of non-English as a primary language, Medicaid insurance, longer distance from the Autism Center, and lower median household income (based on their ZIP code) than the ICF group.

CONCLUSIONS

This study suggests that disparities may have existed in the pre-research recruitment stage. To achieve equity in both clinical and research advancements in autism and related developmental disorders, further efforts are needed to equitably disseminate research opportunities to patients of diverse backgrounds.

Gastrointestinal and Sleep Issues in Toddlers With Autism Versus Other Neurodevelopmental Disorders

Neurodevelopmental disorders (NDDs) are frequently associated with gastrointestinal symptoms (GIS) and sleep issues, but there are insufficient data on the occurrence of these symptoms in young children with autism spectrum disorder (ASD) compared with other NDDs. We abstracted data on 500 children aged 18 to 36 months with ASD and 146 children aged 18 to 47 months with non-ASD NDDs to compare the frequency of these symptoms. In the overall sample, there was a high rate of GIS (46.0%) and sleep difficulties (22.6%). In age-adjusted analyses, children with non-ASD NDDs were more likely to have GIS (61.0% vs 41.6%; adjusted odds ratio [OR] = 2.35; 95% confidence interval = 1.56-3.56) and sleep difficulties (34.9% vs 19.0%; adjusted OR = 2.08; 95% confidence interval = 1.33-3.26) compared with those with ASD. These findings demonstrate the need to assess these symptoms in all young children with developmental concerns to provide appropriate guidance to their families.

Predictors of posttraumatic growth in 475 Chinese parents of children newly diagnosed with autism spectrum disorder

PURPOSE

To examine the predictive effects of children's symptom severity, rumination, parental self-efficacy, and social support on posttraumatic growth (PTG) in parents of autistic children.

DESIGN AND METHODS

Parents (n = 475) completed the demographic questionnaire, Posttraumatic Growth Inventory, Autism Behavior Checklist, Event Related Rumination Inventory, Parenting Sense of Competence, and Social Support Rating Scale in a cross-sectional survey conducted in a tertiary hospital in Guangzhou, China, between September 2019 and January 2021. Multiple linear regression analyses were conducted using SPSS version 25.0.

RESULTS

The PTG score was positively associated with rumination (r = 0.325, P < 0.05), parental self-efficacy (r = 0.219, P < 0.05), and social support (r = 0.374, P < 0.05). Multiple linear regression analysis revealed that household income (β = 0.095, P < 0.05), intrusive rumination (β = -0.100, P < 0.05), deliberate rumination (β = 0.391, P < 0.001), subjective support (β = 0.239, P < 0.001), and children's daily living skills deficiencies as perceived by parents (β = 0.107, P < 0.05) significantly predicted PTG, accounting for 33.3% of the variance [F(P) = 13.444, P < 0.001].

CONCLUSIONS

Psychosocial factors (rumination and subjective support) are essential to facilitate PTG in parents whose children are newly diagnosed with autism.

PRACTICE AND IMPLICATIONS

With the consideration of different sociodemographic features, clinicians and researchers are encouraged to explore cognitive-based psychosocial interventions targeting parents' psychological growth and parenting training programs targeting autistic children's self-care ability.

Impact of Respite Care Services Availability on Stress, Anxiety and Depression in Military Parents who have a Child on the Autism Spectrum

OBJECTIVE

Parenting an autistic child can affect a family's well-being. Finding resources is critical. This pilot study looked at respite's impact on parental stress, anxiety, and depression in military families and demographic factors associated with presence of respite care.

METHOD

Participants completed three surveys on anonymous basis, including two standardized surveys measuring parental stress and anxiety/depression. Data analysis used Chi-square test and regression analysis.

RESULTS

Parents receiving respite reported less stress and anxiety/depression. Respite utilization was associated with absence of comorbid conditions in child and other variables. Predictor variables for parental stress and anxiety/depression included presence of comorbid conditions in child.

CONCLUSION

Respite care may be linked to lower parental stress, anxiety, and depression, but more study is needed.

Caregiver support, burden, and long-term planning among caregivers of individuals with intellectual and developmental disabilities: A cross-sectional study

BACKGROUND

Long-term care planning (LTCP) is critical for individuals with intellectual/developmental disabilities. Objectives of this study were to investigate progression through LTCP, and associations between social support and: (1) LTCP and (2) burden among family caregivers.

METHODS

A cross-sectional survey was distributed to caregivers of individuals with intellectual/developmental disabilities in NY, OH, PA, and TX, exploring demographics, supports, burden, and LTCP behaviours. Bivariate and linear multiple regression analyses were used to investigate study objectives.

RESULTS

Caregivers (n = 405) were predominantly parents, female, non-Hispanic, and in the 'learning to plan' stage of LTCP. Caregiver-identified social support was associated with further progression in LTCP (p = .020) and lower caregiver burden (p < .001).

CONCLUSION

Social support was associated with further progression in LTCP, and associated with less burden, however fewer than 40% of caregivers reported having social support. Ongoing exploration of emotional/social needs of caregivers is necessary to better support these families.

Validation of an Enhanced Telehealth Platform for Toddlers at Increased Likelihood for a Diagnosis of Autism Spectrum Disorder (ASD)

Use of telehealth assessments for toddlers at increased likelihood of autism spectrum disorder (ASD) began prior to the global COVID-19 pandemic; however, the value of telehealth assessments as an alternative to in-person assessment (IPA) became clearer during the pandemic. The Naturalistic Observation Diagnosis Assessment (NODA™), previously demonstrated as a valid and reliable tool to evaluate asynchronous behaviors for early diagnosis, was enhanced to add synchronous collection of behaviors to assist clinicians in making a differential diagnosis of ASD. This study was conducted to validate the information gathered through NODA-Enhanced (NODA-E™) as compared to a gold standard IPA. Forty-nine toddlers aged 16.0-32.1 months of age, recruited through community pediatric offices and a tertiary ASD clinic, participated in both NODA-E and IPA assessments. There was high agreement between the two assessment protocols for overall diagnosis (46 of 49 cases; 93.6%; κ = .878), specific diagnostic criteria for social communication and social interaction (SCI; range 95.9-98%; κ = .918-.959), and for two of four criteria specified for restricted and repetitive behaviors (RRB; range 87.8-98%; κ = .755 and .959). There was lower agreement for two subcategories of RRBs (range 65.3-67.3%; κ = .306 and .347). NODA-E is a tool that can assist clinicians in making reliable and valid early ASD diagnoses using both asynchronous and synchronous information gathered via telehealth and offers an additional tool within a clinician's assessment toolbox.

Community-based care for autistic youth: community providers' reported use of treatment practices in the United States

Introduction

To illustrate the landscape of community-based care for autistic youth in the United States, we identified transdisciplinary psychosocial intervention practice sets that community providers report utilizing to care for this population, and examined characteristics associated with provider-reported utilization.

Methods

The Usual Care for Autism Study (UCAS) Survey assessed provider demographics and provider-reported use of transdisciplinary practices for common ASD co-occurring problems: social difficulties, externalizing behaviors, and anxiety. Community practitioners (N = 701) from allied health, behavioral, education, medical, mental health and other disciplines who treat or work with autistic youth (7-22 years) participated.

Results

Exploratory factor analysis yielded four factors: Consequence-Based Strategies (CBS), Cognitive-Behavioral and Therapy Strategies (CBTS), Antecedent-Based Strategies (ABS), and Teaching Strategies (TS). Providers across disciplines reported utilizing ABS more often than other sets. Providers from behavioral disciplines, with less than 4-year or Master degrees, or with more experience reported the most use of ABS, CBS and CBTS. Medical and behavioral providers reported the most use of TS. Setting and child characteristics were associated with practice set use, indicating variability by disability and client socioeconomic status.

Discussion

Findings reflect the complexity and inconsistency of the service landscape for autistic youth across the U.S. Only by understanding the service landscape and predictors of practice utilization, can researchers, policymakers, provider groups, and the autistic community facilitate effective implementation strategy development and use to ultimately improve community-based care.

Developmental Trajectories of Autism

OBJECTIVES

The goal of this study was to describe the typical, longitudinal, developmental trajectories of communication and social functioning in individuals with autism spectrum disorder from childhood through adulthood and to determine the correlates of these trajectories.

METHODS

Children with autism spectrum disorder who were born in California from 1992 through 2016 and enrolled with the California Department of Developmental Services were identified. Subjects with <4 evaluations in the database were excluded, resulting in a sample of 71 285 individuals. Score sequences were constructed based on evaluative items for communication and social functioning. Typical trajectories were identified using group-based latent trajectory modeling, and logistic regression was used to determine the odds of classification into a social adolescent decline trajectory by individual-, family-, and zip code-level factors.

RESULTS

Six typical patterns of communication functioning and 7 typical patterns of social functioning were identified. Whereas the majority of autistic individuals exhibit improved communication functioning as they age, the majority of individuals exhibit steady social functioning. A small group of individuals (5.0%) exhibits high social functioning in childhood that declines in adolescence. Membership in this adolescent decline group is associated with maternal non-Hispanic white race and ethnicity, female sex, moderate levels of maternal education, lower zip code-level median home values and population density, and higher zip code-level inequality.

CONCLUSIONS

Most autistic individuals show improved communication and social functioning as they age, but not all do. Trajectory group membership is correlated with socioeconomic status. Future research should investigate what drives these correlations.

Priorities, barriers, and facilitators for nutrition-related care for autistic children: a qualitative study comparing interdisciplinary health professional and parent perspectives

Introduction

Children with autism spectrum disorder often face nutrition-related challenges, such as food selectivity, gastrointestinal issues, overweight and obesity, and inadequate nutrient intake. However, the role of routine nutrition-related screening or care by interdisciplinary health professionals is not well understood. This study aimed to compare the beliefs of health professionals with those of parents of autistic children regarding high-priority nutrition-related challenges, barriers and facilitators to care, and desired education and resources related to nutrition for autistic children.

Participants

Interdisciplinary health professionals (n = 25) (i.e., pediatricians, occupational therapists, speech-language pathologists, board certified behavior analysts, registered dietitians) and parents of autistic children (n = 22).

Methods

The study used semi-structured phone interviews, which were recorded, transcribed, verified, and double-coded using the Framework Method.

Results

Thematic analysis of transcripts revealed that while health professionals and parents of autistic children shared some perspectives on nutrition-related challenges and care, they also had distinct viewpoints. Parents emphasized the importance of addressing food selectivity, behavioral eating challenges, sensory issues, and sleep disturbances affecting appetite. Both groups acknowledged the need for tailored support, access to an interdisciplinary care team, and reasonable expectations. Some health professionals perceived parents as lacking motivation or the ability to make changes. In contrast, many parents felt that health professionals lacked the knowledge and motivation to take nutrition or growth concerns seriously. Health professionals acknowledged that their lack of knowledge or capacity to provide nutrition education or referrals was a common barrier to care, particularly given limited community resources.

Discussion

Health professionals who serve autistic children are motivated to address nutrition-related challenges but lack resources related to nutrition. To promote better health outcomes for autistic children, professionals should identify and support parent motivations around nutrition-related care. Both groups expressed interest in accessing autism-specific resources for education, referral, and screening guidance. Future research could explore the development of healthcare training models that improve the competency of health professionals in providing nutrition care and referral for autistic children.

Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents

BACKGROUND AND OBJECTIVES

Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses.

METHODS

This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis.

RESULTS

Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth.

CONCLUSIONS

Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families.

Provider Perspectives on Telehealth Services for Children With Autism Spectrum Disorder During the Coronavirus Disease 2019 Pandemic

OBJECTIVE

The purpose of the current study was to explore provider perspectives on the strengths and challenges of telehealth services (e.g., behavioral interventions, physical, speech, and occupational therapy, medication management) for children with autism spectrum disorder during coronavirus disease 2019 related shutdowns.

METHODS

From September 2020 to May 2021, we conducted qualitative interviews with 35 providers across multiple disciplines from 17 sites in the Autism Care Network. Qualitative data were analyzed using a framework approach and common themes were identified.

RESULTS

Providers across clinical disciplines identified strengths of the virtual model, such as its flexibility and the opportunity it provided to see children in their home environment. They also indicated that some interventions worked better virtually than others, and that there were several factors that impacted their success. Respondents were generally satisfied providing parent-mediated interventions but expressed mixed satisfaction in using telehealth for direct-to-patient care.

CONCLUSIONS

Results suggest that telehealth services for children with autism spectrum disorder could be a helpful tool in decreasing barriers and improving service delivery, especially when tailored to the individual needs of the patient. More research is needed on the factors contributing to its success in order to eventually inform clinical guidelines regarding the prioritization of children seen for in-person visits.

Recommendations for post-implementation adaptations to optimize family navigation in pediatric primary care: a qualitative study with parents and navigators

BACKGROUND

Family Navigation (FN) is an evidence-based care management intervention designed to reduce disparities in access to care by providing families with individually tailored support and care coordination. Early data suggest FN is effective, but effectiveness is significantly influenced by both contextual (e.g. setting) and individual (e.g., ethnicity) variables. To better understand how FN could be tailored to address this variability in effectiveness, we set forth to explore proposed adaptations to FN by both navigators and families who received FN.

METHODS

This study was a nested qualitative study set within a larger randomized clinical trial of FN to improve access to autism diagnostic services in urban pediatric primary care practices in Massachusetts, Pennsylvania, and Connecticut serving low-income, racial and ethnic minority families. Following FN implementation, key informant interviews were conducted based on the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) with a purposeful sample of parents of children who received FN (n = 21) and navigators (n = 7). Interviews were transcribed verbatim and were coded using framework-guided rapid analysis to categorize proposed adaptations to FN.

RESULTS

Parents and navigators proposed 38 adaptations in four domains: 1) content of the intervention (n = 18), 2) context of the intervention (n = 10), 3) training and evaluation (n = 6), and 4) implementation and scale-up (n = 4). The most frequently endorsed adaptation recommendations focused on content (e.g., lengthening FN, providing parents with additional education on autism and parenting children with autism) and implementation (e.g., increasing access to navigation). Although probes targeted critical feedback, parents and navigators were overwhelmingly positive about FN.

CONCLUSIONS

This study builds upon prior FN effectiveness and implementation research by providing concrete areas for adaptation and refinement of the intervention. Recommendations by parents and navigators have the potential to inform improvement of existing navigation programs and development of new programs in similarly underserved populations. These findings are critical as adaptation (cultural and otherwise) is an important principle in the field of health equity. Ultimately, adaptations will need to be tested to determine clinical and implementation effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov, registration number NCT02359084, February 9, 2015.

The Intersection of Autism and Transgender and Nonbinary Identities: Community and Academic Dialogue on Research and Advocacy

Many transgender people are autistic. Community expressions of the autism transgender intersection abound. Some commentators have questioned the proportional overrepresentation of autism among gender-diverse people, suggesting these individuals may not be truly autistic or truly transgender. However, increasing evidence challenges assertions that deny the authenticity of co-occurring autistic and transgender identities. Specifically, research by authors of this article indicates autistic transgender people show neurophenotypes generally consistent with cisgender autistic people and implicit gender phenotypes consistent with nonautistic transgender people. This article features a dialogue between eight leading experts in the field of intersectional autism and gender diversity, including clinicians, researchers, community advocates, and experts who are themselves autistic transgender. Key topics of discussion included: how research findings on autism and gender diversity inform respectful and supportive responses to autistic transgender people; the benefits and harms of increased societal attention toward the autism transgender intersection; and research and advocacy priorities. The expert panel concluded the following: (1) it is important to respect transgender autistic people's wellness and resilience, while also acknowledging the pathologization and stigmatization they face; (2) autistic gender-diverse people are experts of their own identity and should be involved in all aspects of research and clinical care; (3) research is needed to understand the disparities autistic transgender people face; (4) attempts to restrict autistic transgender people's access to gender care are unsupported by existing research; (5) adult gender care may benefit from incorporating universal design principles and neurodiversity-affirming strategies to reduce barriers to care and improve clinician-client communication in treatment delivery and the informed consent process; (6) cross-cultural and cross-societal research will improve best care practices in diverse contexts; (7) research and advocacy must be inclusive across ethnoracial identities, including in leadership and perspectives represented; and (8) a life span developmental framework is needed for adult research in this field.