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Zheng RM, Chan SP, Law EC, Chong SC, Aishworiya R. Validity and feasibility of using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) in primary care clinics in Singapore. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024; 28:1758-1771. [PMID: 37882198 PMCID: PMC11191374 DOI: 10.1177/13623613231205748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
LAY ABSTRACT Systematic screening for autism in early childhood has been suggested to improve eventual outcomes by facilitating earlier diagnosis and access to intervention. However, clinical implementation of screening has to take into account effectiveness and feasibility of use within a healthcare setting for accurate diagnosis of autism. In Singapore, autism screening using a structured screening tool is not currently employed as a part of routine well-child visits for children in primary care clinics. In this study, 5336 children (aged 17-20 months) were screened for autism using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) during their 18-month well-child visit in seven primary care clinics. Screening and follow-up interviews were administered by nursing staff at each clinic. Children screened positive and a portion of those screened negative then underwent diagnostic assessments to determine whether they met the diagnostic criteria for autism. In total, 113 (2.1%) were screened positive, of which 54 (1.0%) met the criteria for autism. Children who screened positive and received a diagnosis accessed autism-specific intervention at an average age of 22 months. Nurses and physicians rated the acceptability and practicality of the M-CHAT-R/F highly. Therefore, the M-CHAT-R/F questionnaire was an effective and feasible tool for autism screening among 18-month-old children in this study. Future studies will be designed to determine the optimal age of screening and role of repeated screening in Singapore, as well as to better understand any potential improved outcomes nationwide compared with pre-implementation of autism screening.
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Affiliation(s)
| | - Siew Pang Chan
- National University Heart Centre, Singapore
- National University of Singapore, Singapore
| | - Evelyn C Law
- National University of Singapore, Singapore
- Agency for Science, Technology and Research (A*STAR), Singapore
- National University Hospital, Singapore
| | - Shang Chee Chong
- National University of Singapore, Singapore
- National University Hospital, Singapore
| | - Ramkumar Aishworiya
- National University of Singapore, Singapore
- National University Hospital, Singapore
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Wallis KE, Usher R. Applying autism screening research to real-world scenarios: a commentary on Sheldrick et al. (2023). J Child Psychol Psychiatry 2024; 65:720-722. [PMID: 38009449 DOI: 10.1111/jcpp.13919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 11/28/2023]
Abstract
Early identification of autism spectrum disorder (ASD) continues to be a challenge despite universal screening efforts. One explanation is that screening tools have lower sensitivity and specificity than initial studies report when accounting for incomplete follow-up for all children screened. Sheldrick and colleagues used statistical modeling to demonstrate the impact on sensitivity and specificity when assumptions about the diagnostic outcome of children who do not pursue diagnostic evaluation are altered. Crucially, the work of Sheldrick et al. serves as a reminder that autism screening in primary care is just one component of the clinical assessment and should not be conflated with a diagnostic evaluation. Thus, lack of follow-up after a positive screen is a feature, not only a bug when using a screen in a clinical setting. Engaging families in shared decision-making around screening may help encourage follow-up, and thus, screening tool psychometric performance.
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Affiliation(s)
- Kate E Wallis
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rosalind Usher
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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3
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Wallis KE, Guthrie W. Screening for Autism: A Review of the Current State, Ongoing Challenges, and Novel Approaches on the Horizon. Pediatr Clin North Am 2024; 71:127-155. [PMID: 38423713 DOI: 10.1016/j.pcl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
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.
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Affiliation(s)
- Kate E Wallis
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Whitney Guthrie
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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4
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Hamdan SZ, Davis M, Faig W, Guthrie W, Yerys BE, Wallis KE. Lower Completion of Depression Screening and Higher Positivity Among Autistic Adolescents Across a Large Pediatric Primary Care Network. Acad Pediatr 2023; 23:1561-1571. [PMID: 37393034 PMCID: PMC10755081 DOI: 10.1016/j.acap.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/17/2023] [Accepted: 06/23/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVE To examine rates of depression screening and positivity among autistic adolescents where electronic depression screening is administered universally; to compare rates between autistic and nonautistic youth; and to explore sociodemographic and clinical factors associated with screening completion and results. METHODS We conducted a retrospective cohort study comparing 12-17-year-old autistic and nonautistic adolescents presenting for well-child care in a large pediatric primary care network between November 2017 and January 2019 (N = 60,181). Sociodemographic and clinical data, including PHQ-9-M completion status and results, were extracted digitally from the electronic health record and compared between autistic and nonautistic youth. Logistic regression explored the relationship between sociodemographic and clinical factors and screen completion and results, stratified by autism diagnosis. RESULTS Autistic adolescents were significantly less likely to have a completed depression screen compared to nonautistic adolescents [67.0% vs 78.9%, odds ratio (OR) = 0.54, P < .01]. Among those with a completed screen, a higher percentage of autistic youths screened positive for depression (39.1% vs 22.8%; OR = 2.18, P < .01,) and suicidal ideation/behavior (13.4% vs 6.8%; OR = 2.13, P < .01). Factors associated with screening completion and positivity differed between autistic and nonautistic groups. CONCLUSIONS Autistic adolescents were less likely to have a completed depression screen when presenting for well-child care. However, when screened, they were more likely to endorse depression and suicide risk. This suggests disparities in depression screening and risk among autistic youth compared to nonautistic youth. Additional research should evaluate the source of these disparities, explore barriers to screening, and examine longitudinal outcomes of positive results among this population.
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Affiliation(s)
- Samar Z Hamdan
- Division of Developmental and Behavioral Pediatrics (SZ Hamdan, W Guthrie, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics (SZ Hamdan, W Guthrie, and KE Wallis), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Molly Davis
- Department of Child and Adolescent Psychiatry and Behavioral Sciences (M Davis, W Guthrie, and BE Yerys), Children's Hospital of Philadelphia, Philadelphia, Pa; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI) (M Davis), University of Pennsylvania, Philadelphia, Pa; Department of Psychiatry (M Davis, W Guthrie, and BE Yerys), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Walter Faig
- Biostatistics and Data Management Core (W Faig), Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Whitney Guthrie
- Division of Developmental and Behavioral Pediatrics (SZ Hamdan, W Guthrie, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics (SZ Hamdan, W Guthrie, and KE Wallis), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Department of Child and Adolescent Psychiatry and Behavioral Sciences (M Davis, W Guthrie, and BE Yerys), Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Psychiatry (M Davis, W Guthrie, and BE Yerys), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Center for Autism Research (W Guthrie, BE Yerys, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa; Clinical Futures (W Guthrie, BE Yerys, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa. Dr Hamdan is now with the Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.
| | - Benjamin E Yerys
- Department of Child and Adolescent Psychiatry and Behavioral Sciences (M Davis, W Guthrie, and BE Yerys), Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Psychiatry (M Davis, W Guthrie, and BE Yerys), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Center for Autism Research (W Guthrie, BE Yerys, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa; Clinical Futures (W Guthrie, BE Yerys, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa. Dr Hamdan is now with the Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.
| | - Kate E Wallis
- Division of Developmental and Behavioral Pediatrics (SZ Hamdan, W Guthrie, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics (SZ Hamdan, W Guthrie, and KE Wallis), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Center for Autism Research (W Guthrie, BE Yerys, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa; Clinical Futures (W Guthrie, BE Yerys, and KE Wallis), Children's Hospital of Philadelphia, Philadelphia, Pa. Dr Hamdan is now with the Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.
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Stadnick NA, Aarons GA, Martinez K, Sklar M, Coleman KJ, Gizzo DP, Lane E, Kuelbs CL, Brookman-Frazee L. Implementation outcomes from a pilot of "Access to Tailored Autism Integrated Care" for children with autism and mental health needs. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2022; 26:1821-1832. [PMID: 35083919 PMCID: PMC9325918 DOI: 10.1177/13623613211065801] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
LAY ABSTRACT Children with autism frequently experience co-occurring mental health needs. The "Access to Tailored Autism Integrated Care (ATTAIN)" model was co-created with caregivers, pediatric providers, and health care leaders to identify mental health needs and link to mental health care for autistic children. This article describes outcomes from a pilot study of Access to Tailored Autism Integrated Care with 36 pediatric primary care providers from seven clinics within three healthcare systems. Providers participated in an initial Access to Tailored Autism Integrated Care training and received ongoing online support over 4 months with autistic patients ages 4-16 years old. Survey and interview assessments measured provider perceptions of feasibility, acceptability, and intentions to continue using Access to Tailored Autism Integrated Care after the pilot. Providers reported that Access to Tailored Autism Integrated Care was feasible, acceptable, that the initial training was helpful in their implementation but that more specific and tailored implementation support was needed. Results show that Access to Tailored Autism Integrated Care is a promising model to support mental health screening and linkage for children with autism in primary care. Findings provide information on specific areas of the Access to Tailored Autism Integrated Care model that could be benefit from additional refinement to support more widespread use in primary care settings.
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Affiliation(s)
- Nicole A Stadnick
- University of California San Diego, La Jolla, CA, USA
- UC San Diego Altman Clinical and Translational Research Institute CA, Dissemination and Implementation Science Center, USA
- Child and Adolescent Services Research Center, USA
| | - Gregory A Aarons
- University of California San Diego, La Jolla, CA, USA
- UC San Diego Altman Clinical and Translational Research Institute CA, Dissemination and Implementation Science Center, USA
- Child and Adolescent Services Research Center, USA
| | - Kassandra Martinez
- Child and Adolescent Services Research Center, USA
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, USA
| | - Marisa Sklar
- University of California San Diego, La Jolla, CA, USA
- UC San Diego Altman Clinical and Translational Research Institute CA, Dissemination and Implementation Science Center, USA
- Child and Adolescent Services Research Center, USA
| | | | | | - Elizabeth Lane
- University of California San Diego, La Jolla, CA, USA
- Child and Adolescent Services Research Center, USA
| | - Cynthia L Kuelbs
- University of California San Diego, La Jolla, CA, USA
- Rady Children's Hospital, San Diego, CA, USA
| | - Lauren Brookman-Frazee
- University of California San Diego, La Jolla, CA, USA
- UC San Diego Altman Clinical and Translational Research Institute CA, Dissemination and Implementation Science Center, USA
- Child and Adolescent Services Research Center, USA
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6
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Abstract
The rural areas have been at the receiving end amidst mental health disparity across the USA. There is a serious and concerning divide among ones with autism spectrum disorders (ASDs) living in underserved areas as compared to urban residents. With the higher than ever prevalence of ASD as per the recent reports of the Centers for Disease Control and Prevention; there is a need for a closer look at the prevailing issues. The trends are reflecting marked underdiagnosis, late diagnosis, lack of evidence-based diagnostic measures and interventions. These factors interplay in worsening the mental health crisis and there is an urgent need for corrective measures to address these highly modifiable problems.
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MacDuffie KE, Estes AM, Harrington LT, Peay HL, Piven J, Pruett JR, Wolff JJ, Wilfond BS. Presymptomatic Detection and Intervention for Autism Spectrum Disorder. Pediatrics 2021; 147:e2020032250. [PMID: 33853890 PMCID: PMC8085996 DOI: 10.1542/peds.2020-032250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
Universal screening for autism spectrum disorder (ASD) is recommended during pediatric primary care visits in the first 2 years of life. However, many children are missed by initial screening and not diagnosed with ASD until years later. Research efforts are underway to develop and evaluate new objective measures of risk for ASD that can be used in infancy, before symptoms emerge. Initial studies with these tests, particularly MRI-based screening for infants at high familial risk, have shown promise but have not yet been evaluated in clinical trials. We present the study design for a hypothetical clinical trial that would combine presymptomatic detection and intervention for ASD and consider, through commentaries from diverse perspectives, the ethical issues that should be anticipated in advance of beginning such trials. Commentators Drs Pruett and Piven address the social value of the proposed research and importance of researcher-bioethicist collaborations. Drs Estes and Wolff discuss the clinical potential and challenges of developing presymptomatic interventions for infants at risk for ASD. Dr Harrington takes a neurodiversity view of presymptomatic prediction and intervention and their implications for autistic identity and quality of life. Finally, Drs MacDuffie, Peay and Wilfond consider the potential risks and benefits that must be evaluated and weighed in the next phases of research on presymptomatic detection and intervention for ASD.
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Affiliation(s)
- Katherine E MacDuffie
- Departments of Speech and Hearing Sciences and
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | | | | | - Holly L Peay
- Research Triangle Institute International, Research Triangle Park, North Carolina
| | - Joseph Piven
- Carolina Institute for Developmental Disabilities, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - John R Pruett
- School of Medicine, Washington University, St Louis, Missouri; and
| | - Jason J Wolff
- Department of Educational Psychology, University of Minnesota, Minneapolis, Minnesota
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
- Pediatrics, University of Washington, Seattle, Washington
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Wallis KE, Buttenheim AM, Mandell DS. Insights from Behavioral Economics: A Case of Delayed Diagnosis of Autism Spectrum Disorder. J Dev Behav Pediatr 2021; 42:109-113. [PMID: 33003116 DOI: 10.1097/dbp.0000000000000869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/01/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT We present the case of a child of color diagnosed with autism spectrum disorder (ASD) at 67 months of age. Drawing from behavioral economics, we used this case to explore errors in decision-making by clinicians and family members and structural factors that may have delayed ASD diagnosis well beyond the national average.
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Affiliation(s)
- Kate E Wallis
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alison M Buttenheim
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - David S Mandell
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Mental Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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9
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Abstract
CASE Brian is a 6-year-old boy who was diagnosed with autism spectrum disorder (ASD) and global developmental delay at age 2. He has no other health conditions of note. Brian lives with his parents and an older brother, who also has ASD, in a rural area 2 hours from the center where he was diagnosed. Brian has a history of intermittent self-injurious behaviors (head-banging, throwing himself onto the floor, etc.) that regularly result in bruising, intense and lengthy tantrums, and aggression toward family and teachers. Brian will occasionally indicate items that he wants, but otherwise has no functional communication skills. Over the past 18 months, Brian's challenging behaviors have waxed and waned. The regional special education program is not equipped to safely manage his behaviors, and there are no in-home or center-based agencies that provide applied behavior analysis (ABA) available. Brian's developmental pediatrician initiated guanfacine (eventually adding a small dose of aripiprazole) and referred the family to psychology for weekly telehealth behavioral parent training to address behavioral concerns using the Research Units in Behavioral Intervention curriculum.1Brian's behavioral problems decreased during the initial weeks of the COVID-19 crisis, when he no longer had to leave home or attend special education. However, as summer continued, his behaviors worsened substantially (regular bruising and tissue damage, numerous after-hours consultations with his psychologist and developmental pediatrician, and one trip to the emergency department). The intensity of Brian's behaviors (maintained primarily by access to tangible items and escape from demands) made progress with behavioral supports slow and discouraging for his parents. Other psychosocial stressors coalesced for the family as well, including employment loss, limited social support because of social distancing requirements, and illness of one of his parents. The developmental pediatrician continued to modify the medication regimen over the summer, transitioning Brian from guanfacine to clonidine and increasing his aripiprazole incrementally (with clear increased benefit); hydroxyzine was also used as needed during the episodes of highest intensity.Despite the availability of best-practice guidelines for children with Brian's presenting concerns,2 a confluence of barriers (geographic, economic, ABA work force, global pandemic, etc.) present serious questions for his family and care team related to the next steps in Brian's care. Should he attend in-person school in the fall, knowing that the available program may have limited educational benefit and increase his risk of COVID-19 exposure (not to mention self-injury)? Would the potential benefits of cross-country travel to an intensive behavioral treatment program outweigh the associated psychosocial and economic stressors? How else can the virtual care team support this family? REFERENCES 1. Bearss K, Johnson C, Smith T, et al. Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial. JAMA. 2015;313: 1524-1533.2. Hyman SL, Levy SE, Myers SM, et al. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics. 2020;145:e20193447.
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