Updates to the Autism Intervention Research Network on Physical Health (AIR-P) Research Agenda

INTRODUCTION

Autistic individuals, now representing one in 36 individuals in the U.S., experience disproportionate physical health challenges relative to non-autistic individuals. The Health Resources and Services Administration's (HRSA) Autism Intervention Research Network on Physical Health (AIR-P) is an interdisciplinary, multi-center Research Network that aims to increase the health, well-being, and quality of life of autistic individuals. The current paper builds on the initial AIR-P Research Agenda (proposed in Year 1) and provides an updated vision for the Network.

METHODS

Updates to the Research Agenda were made via the administration of a Qualtrics survey, and disseminated widely to all AIR-P entities, including the Research Node Leaders, Steering Committee, Autistic Researcher Review Board, and collaborating academic and non-academic entities. Network members were tasked with evaluating the Year 1 Research Agenda and proposing additional priorities.

RESULTS

Within each Research Node, all Year 1 priorities were endorsed as continued priorities for research on autism and physical health. Specific topics, including co-occurring conditions and self-determination, advocacy, and decision-making, were particularly endorsed. Opportunities for exploratory studies and intervention research were identified across Research Nodes. Qualitative responses providing feedback on additional research priorities were collected.

CONCLUSION

The updated AIR-P Research Agenda represents an important step toward enacting large-scale health promotion efforts for autistic individuals across the lifespan. This updated agenda builds on efforts to catalyze autism research in historically underrepresented topic areas while adopting a neurodiversity-oriented approach to health promotion.

State Policies that Impact the Design of Children's Mental Health Services: A Modified Delphi Study

To identify the state-level policies and policy domains that state policymakers and advocates perceive as most important for positively impacting the use of children's mental health services (CMHS). We used a modified Delphi technique (i.e., two rounds of questionnaires and an interview) during Spring 2021 to elicit perceptions among state mental health agency officials and advocates (n = 28) from twelve states on state policies that impact the use of CMHS. Participants rated a list of pre-specified policies on a 7-point Likert scale (1 = not important, 7 = extremely important) in the following policy domains: insurance coverage and limits, mental health services, school and social. Participants added nine policies to the initial list of 24 policies. The "school" policy domain was perceived as the most important, while the "social" policy domain was perceived as the least important after the first questionnaire and the second most important policy domain after the second questionnaire. The individual policies perceived as most important were school-based mental health services, state mental health parity, and Medicaid reimbursement rates. Key stakeholders in CMHS should leverage this group of policies to understand the current policy landscape in their state and to identify gaps in policy domains and potential policy opportunities to create a more comprehensive system to address children's mental health from a holistic, evidence-based policymaking perspective.

The Autism Intervention Research Network on Physical Health (AIR-P) Research Agenda

OBJECTIVES

In the United States, autistic individuals experience disproportionate physical and mental health challenges relative to non-autistic individuals, including higher rates of co-occurring and chronic conditions and lower physical, social, and psychological health-related quality of life. The Autism Intervention Research Network on Physical Health (AIR-P) is an interdisciplinary, multicenter research network for scientific collaboration and infrastructure that aims to increase the life expectancy and quality of life for autistic individuals, with a focus on underserved or vulnerable populations. The current paper describes the development of the AIR-P Research Agenda.

METHODS

Development of the research agenda involved an iterative and collaborative process between the AIR-P Advisory Board, Steering Committee, and Autistic Researcher Review Board. The methodology consisted of 3 phases: (1) ideation and design, (2) literature review and synthesis; and (3) network engagement.

RESULTS

Six core research priorities related to the health of autistic individuals were identified: (1) primary care services and quality, (2) community-based lifestyle interventions, (3) health systems and services, (4) gender, sexuality, and reproductive health, (5) neurology, and (6) genetics. Specific topics within each of these priorities were identified. Four cross-cutting research priorities were also identified: (1) neurodiversity-oriented care, (2) facilitating developmental transitions, (3) methodologically rigorous intervention studies, and (4) addressing health disparities.

CONCLUSIONS

The AIR-P Research Agenda represents an important step forward for enacting large-scale health-promotion efforts for autistic individuals across the lifespan. This agenda will catalyze autism research in historically underrepresented topic areas while adopting a neurodiversity-oriented approach to health-promotion.

Implementation of a pharmacist and student pharmacist-led primary care service to identify and treat rural veterans at risk for osteoporotic fracture

OBJECTIVE

To develop and implement a pharmacist and student pharmacist-led osteoporosis service to increase dual-energy x-ray absorptiometry (DXA) screening rates among rural veterans and treat those at high risk of osteoporotic fractures.

PRACTICE DESCRIPTION

Pharmacists are uniquely positioned to provide direct patient care in the Department of Veterans Affairs ambulatory care setting owing to their broad scope of practice. Clinical Pharmacy Specialists (CPSs) have the authority to order laboratory tests and imaging, prescribe medications, refer patients to specialty services, and monitor patients along with the primary care team.

PRACTICE INNOVATION

The implementation of a pharmacist-led osteoporosis primary prevention service using student pharmacists to identify and treat patients has not been previously described in the literature to the authors' knowledge.

EVALUATION METHODS

Student pharmacists in their third year contacted veterans who met the inclusion criteria for osteoporosis screening. The veterans were offered DXA scans and provided education on the risk factors for osteoporosis. After the DXA scans were completed, the students and the CPS reviewed the results to determine treatment strategies. The primary objective was evaluated by comparing the pre- and post-implementation rates of DXA screening. The other process markers that were evaluated included (1) completed DXA scans, (2) new diagnoses of osteoporosis or osteopenia, (3) patients eligible for treatment on the basis of the DXA screening results, and (4) patients who started oral bisphosphonate therapy.

RESULTS

Of the 232 rural veterans evaluated, 36 had completed DXA scans before this service was implemented. After the service was implemented, 115 veterans completed DXA scans. A total of 57 patients received a new diagnosis, 33 were eligible for therapy, and 12 started oral bisphosphonate therapy after intervention by the CPS.

CONCLUSION

The implementation of a pharmacist-driven osteoporosis screening and treatment service demonstrated an increase in the rate of DXA screening among rural veterans.

Timing of the Diagnosis of Autism in African American Children

OBJECTIVES

African American (AA) children affected by autism spectrum disorder (ASD) experience delays in diagnosis and obstacles to service access, as well as a disproportionate burden of intellectual disability (ID) as documented in surveillance data recently published by the US Centers for Disease Control and Prevention. Our objective in this study was to analyze data from the largest-available repository of diagnostic and phenotypic information on AA children with ASD, and to explore the wide variation in outcome within the cohort as a function of sociodemographic risk and specific obstacles to service access for the purpose of informing a national approach to resolution of these disparities.

METHODS

Parents of 584 AA children with autism consecutively enrolled in the Autism Genetic Resource Exchange across 4 US data collection sites completed event history calendar interviews of the diagnostic odysseys for their children with ASD. These data were examined in relation to developmental outcomes of the children with autism and their unaffected siblings.

RESULTS

The average age of ASD diagnosis was 64.9 months (±49.6), on average 42.3 months (±45.1) after parents' first concerns about their children's development. The relationship between timing of diagnosis and ASD severity was complex, and ID comorbidity was not predicted in a straightforward manner by familial factors associated with cognitive variation in the general population.

CONCLUSIONS

These findings document significant opportunity to expedite diagnosis, the need to further understand causes of ID comorbidity, and the necessity to identify effective approaches to the resolution of disparities in severity-of-outcome for AA children with autism.

Setbacks and Successes: How Young Adults on the Autism Spectrum Seek Friendship

Objective

To describe the perspectives of young adults on the autism spectrum about how they seek and make friends and explore the diverse ways that some develop satisfying friendships despite social difficulties.

Methods

We conducted semistructured interviews with 20 young adults on the autism spectrum about their lives after high school. Although interviews covered a broad range of topics related to transition, the subject of friendship came up frequently throughout the interviews. We extracted data specifically related to friendship for this article and used an inductive approach derived from grounded theory to identify and examine concepts.

Results

Participants had the most success in relationships in which their atypical behavior was normalized. Specifically, this occurred among friends who accepted and appreciated their social differences and through common interests where these differences were not a concern. In other relationships, participants felt that they were expected to adhere to social norms, but found it uncomfortable and/or were not sure how to act in some contexts. Therefore, finding friends who did not expect this was a welcome relief. Participants who were socially isolated wanted more opportunities to meet other people, such as organized social groups, but were not sure how to access these.

Conclusion

Results suggest that friendship, although challenging, can be navigated successfully for some young adults on the autism spectrum. These findings have implications for supporting young adults in their efforts to make friends in ways that work best for them and for creating measures that more accurately reflect their perspectives and needs. Reframing the concept of friendship to include a wider array of experiences and perspectives, identifying successful strategies, and creating more accurate assessments could present a very different picture of friendship and contribute to better outcomes for this unique population.

Lay Summary

Background:: Young adults on the autism spectrum often have difficulty making friends due to challenges with social communication. Nevertheless, some do enjoy friendships with their peers. The purpose of this article is to describe friendship seeking from the perspectives of young adults on the autism spectrum and explore the diverse ways that some develop satisfying friendships despite social difficulties. This information can be used to support young adults in their efforts to make friends by identifying the approaches and strategies that work best for them.About This Study:: The information in this article comes from a study we conducted about the transition to adulthood for young adults. We interviewed 20 young adults about their life experiences in their late teens and 20s. Friendship was very important for most of them and they described their desires to have friends, their efforts to make friends, and the significant difficulties and frustrations they faced. They attributed these difficulties to being seen as different from others and too few opportunities to socialize. They had the most success by finding friends who accepted and appreciated their social differences. In these relationships, they did not have to worry about social norms the way they usually did. Several participants found it easier to relate to others on the spectrum and participated in organized social groups. Still others made friends around shared interests where their autism was not a primary concern. Overall, our interviews showed that young adults on the autism spectrum seek friends in a variety of ways.What This Information Tells Us:: Researchers and service providers often conclude that friendship for people on the autism spectrum is lacking when compared with their typically developing peers. However, the experiences of some young adults can tell a story of difference rather than deficit. From this and other studies, it is clear that people on the autism spectrum may perceive friendship differently, have different priorities or goals for friendship, and have different ways of seeking and experiencing friendship than their typical peers. If we broaden our ideas of friendship to be more inclusive, things might appear very differently. Even so, many young adults struggle to make friends. By understanding their experiences with friendship, identifying where they need help, and identifying strategies and approaches that might work best for them, we can better support their efforts.

The Prevalence of Parent-Reported Autism Spectrum Disorder Among US Children

: media-1vid110.1542/5839990273001PEDS-VA_2017-4161Video Abstract OBJECTIVES: To estimate the national prevalence of parent-reported autism spectrum disorder (ASD) diagnosis among US children aged 3 to 17 years as well as their treatment and health care experiences using the 2016 National Survey of Children's Health (NSCH).

METHODS

The 2016 NSCH is a nationally representative survey of 50 212 children focused on the health and well-being of children aged 0 to 17 years. The NSCH collected parent-reported information on whether children ever received an ASD diagnosis by a care provider, current ASD status, health care use, access and challenges, and methods of treatment. We calculated weighted prevalence estimates of ASD, compared health care experiences of children with ASD to other children, and examined factors associated with increased likelihood of medication and behavioral treatment.

RESULTS

Parents of an estimated 1.5 million US children aged 3 to 17 years (2.50%) reported that their child had ever received an ASD diagnosis and currently had the condition. Children with parent-reported ASD diagnosis were more likely to have greater health care needs and difficulties accessing health care than children with other emotional or behavioral disorders (attention-deficit/hyperactivity disorder, anxiety, behavioral or conduct problems, depression, developmental delay, Down syndrome, intellectual disability, learning disability, Tourette syndrome) and children without these conditions. Of children with current ASD, 27% were taking medication for ASD-related symptoms, whereas 64% received behavioral treatments in the last 12 months, with variations by sociodemographic characteristics and co-occurring conditions.

CONCLUSIONS

The estimated prevalence of US children with a parent-reported ASD diagnosis is now 1 in 40, with rates of ASD-specific treatment usage varying by children's sociodemographic and co-occurring conditions.

Network Measures of Collaborative Support for Young Adults With Autism

OBJECTIVES

The treatment of autism requires complex, multimodal interventions, provided by parents and providers across settings. As young adults with autism spectrum disorder (ASD) transition into adulthood, new stakeholders are added to support planning for postsecondary employment. In this article, we investigate the use of dynamic social network measures that describe the resources of young adults throughout transition.

METHODS

A longitudinal, dynamic social network survey (Social Dynamics of Intervention [SoDI]) was conceptualized, designed, and conducted as a feasibility test, measuring changes in collaboration among parents and school staff members who provided interventions for children with ASD in 2 urban public schools. Using the SoDI, we tracked the following over time: the team who provided interventions, their locations, the interventions they provided, the autism trainings they attended, and the density of the team's problem-solving network for the child.

RESULTS

Using the SoDI, we successfully identified stakeholders across settings who provided interventions for each child. Results indicated variation in the density of problem-solving and trust related to ASD intervention across teams as well as variation in intervention and autism knowledge networks during the school year. Adaptations of the SoDI for mapping pre- and posttransition resources and social connectivity across stakeholders for young adults with ASD are proposed in the Discussion section.

CONCLUSIONS

Dynamic social network approaches can be used to capture changes in intervention, autism knowledge, and social connectivity, providing informative descriptive data about how vocational rehabilitation policies might increase employment supports during the transition process for young adults with ASD.

Stakeholder Perspectives on Research and Practice in Autism and Transition

OBJECTIVES

Individuals with autism spectrum disorder (ASD) are reported to experience significant challenges during the transition to adulthood. Although recent evidence indicates that individuals with ASD experience poor outcomes in adulthood, little is understood about the contributing factors. In this qualitative study, we investigated the barriers to and needs in research and practice in the transition to adulthood among individuals with ASD.

METHODS

Thirteen researchers, including service providers, family members, and an individual with ASD participated in 30- to 60-minute, semistructured, open-ended telephone interviews. Interviews were transcribed, and data were analyzed by using an inductive approach to identify themes related to barriers to and needs in the transition to adulthood for youth with ASD.

RESULTS

Stakeholders identified the need for transition planning and preparation to begin earlier and for systems to better accommodate the interests and varying abilities of individuals with ASD. Stakeholders also felt that parent and service provider expectations and perceptions influence early opportunities and experiences offered throughout the transition process.

CONCLUSIONS

This study reveals the multilevel barriers to and needs in the transition to adulthood and the need for interagency and multidisciplinary collaboration and research to address the varying levels of needs, abilities, and multisector challenges.

Parents' and young adults' perspectives on transition outcomes for young adults with autism

Existing research shows that young adults with autism spectrum disorder have poorer outcomes than their peers with other developmental disabilities in the key areas of independent living, postsecondary education, and employment. However, we understand little about how young adults with autism and their families understand and value outcomes and whether these indicators match their goals and aspirations. We interviewed parents (n = 21) and young adults with autism spectrum disorder (n = 20) about their experiences with the transition to adulthood to understand what they consider to be desirable outcomes and how they seek to achieve them. Understanding these perspectives will help identify areas of need as well as disconnections between service objectives and the goals of young adults and their families. Participants described outcomes as more complex and nuanced than current conceptions and measures account for. They defined and evaluated outcomes in relation to their or their child's individual abilities, needs, and desires. These findings provide important insight into challenges to and facilitators of desired outcomes, which has implications for programming, service delivery, and policy.

An audience research study to disseminate evidence about comprehensive state mental health parity legislation to US State policymakers: protocol

BACKGROUND

A large proportion of the US population has limited access to mental health treatments because insurance providers limit the utilization of mental health services in ways that are more restrictive than for physical health services. Comprehensive state mental health parity legislation (C-SMHPL) is an evidence-based policy intervention that enhances mental health insurance coverage and improves access to care. Implementation of C-SMHPL, however, is limited. State policymakers have the exclusive authority to implement C-SMHPL, but sparse guidance exists to inform the design of strategies to disseminate evidence about C-SMHPL, and more broadly, evidence-based treatments and mental illness, to this audience. The aims of this exploratory audience research study are to (1) characterize US State policymakers' knowledge and attitudes about C-SMHPL and identify individual- and state-level attributes associated with support for C-SMHPL; and (2) integrate quantitative and qualitative data to develop a conceptual framework to disseminate evidence about C-SMHPL, evidence-based treatments, and mental illness to US State policymakers.

METHODS

The study uses a multi-level (policymaker, state), mixed method (QUAN→qual) approach and is guided by Kingdon's Multiple Streams Framework, adapted to incorporate constructs from Aarons' Model of Evidence-Based Implementation in Public Sectors. A multi-modal survey (telephone, post-mail, e-mail) of 600 US State policymakers (500 legislative, 100 administrative) will be conducted and responses will be linked to state-level variables. The survey will span domains such as support for C-SMHPL, knowledge and attitudes about C-SMHPL and evidence-based treatments, mental illness stigma, and research dissemination preferences. State-level variables will measure factors associated with C-SMHPL implementation, such as economic climate and political environment. Multi-level regression will determine the relative strength of individual- and state-level variables on policymaker support for C-SMHPL. Informed by survey results, semi-structured interviews will be conducted with approximately 50 US State policymakers to elaborate upon quantitative findings. Then, using a systematic process, quantitative and qualitative data will be integrated and a US State policymaker-focused C-SMHPL dissemination framework will be developed.

DISCUSSION

Study results will provide the foundation for hypothesis-driven, experimental studies testing the effects of different dissemination strategies on state policymakers' support for, and implementation of, evidence-based mental health policy interventions.

Postsecondary pathways and persistence for STEM versus non-STEM majors: among college students with an autism spectrum disorder

Little is known about postsecondary pathways and persistence among college students with an autism spectrum disorder (ASD). This study analyzed data from the National Longitudinal Transition Study-2, 2001-2009, a nationally representative sample of students in special education with an ASD who progressed from high school to postsecondary education. Findings suggest that most college students with an ASD enrolled in a 2-year community college at some point in the postsecondary careers (81%). Those in science, technology, engineering and mathematics (STEM) fields were more likely to persist in a 2-year community college and were twice as likely to transfer from a 2-year community college to a 4-year university than their peers in the non-STEM fields. College persistence rates varied by gender, race, parent education level, and college pathway and major. Educational policy implications are discussed.

Special Education Services Received by Students with Autism Spectrum Disorders from Preschool through High School

Little is known about how special education services received by students with Autism Spectrum Disorders (ASDs) differ by age, disability severity, and demographic characteristics. Using three national datasets, the Pre-Elementary Education Longitudinal Study (PEELS), the Special Education Elementary Longitudinal Study (SEELS), and the National Longitudinal Transition Study-2 (NLTS2), this study examined the age trends in special education services received by students with ASDs from preschool through high school. Elementary-school students with ASDs had higher odds of receiving adaptive physical education, specialized computer software or hardware, and special transportation, but lower odds of receiving learning strategies/study skills support than their preschool peers. Secondary-school students had lower odds of receiving speech/language or occupational therapy and of having a behavior management program, but higher odds of receiving mental health or social work services than their elementary-school peers. Both disability severity and demographic characteristics were associated with differences in special education service receipt rates.

Trajectory of development in adolescents and adults with autism

This article seeks to elucidate the trajectory of development in adolescents and adults with autism. Prospective, retrospective, and cross-sectional studies are reviewed to reveal the manifestation of and changes in the core symptoms of autism in adolescence and adulthood. Comparing children with adolescents and adults, modest degrees of symptom abatement and improvement in skills have been documented in multiple studies, as are increases in verbal and decreases in performance IQ. Nevertheless, most individuals do not attain normative outcomes in adulthood and continue to manifest significant degrees of symptomatology and dependency. However, a small sub-group (about 15%) has more favorable adult outcomes.

Psychological well-being and coping in mothers of youths with autism, Down syndrome, or fragile X syndrome

The psychological well-being of mothers raising a child with a developmental disability varies with the nature of the disability. Most research, however, has been focused on Down syndrome and autism. We added mothers whose adolescent or young adult son or daughter has fragile X syndrome. The sample was comprised of mothers of a child with fragile X syndrome (n = 22), Down syndrome (n = 39), or autism (n = 174). Mothers of individuals with fragile X syndrome displayed lower levels of well-being than those of individuals with Down syndrome, but higher levels than mothers of individuals with autism, although group differences varied somewhat across different dimensions of well-being. The most consistent predictor of maternal outcomes was the adolescent or young adult's behavioral symptoms.

Psychological Well-Being and Coping in Mothers of Youths With Autism, Down Syndrome, orFragile X Syndrome

The psychological well-being of mothers raising a child with a developmental disability varies with the nature of the disability. Most research, however, has been focused on Down syndrome and autism. We added mothers whose adolescent or young adult son or daughter has fragile X syndrome. The sample was comprised of mothers of a child with fragile X syndrome (n = 22), Down syndrome (n = 39), or autism (n = 174). Mothers of individuals with fragile X syndrome displayed lower levels of well-being than those of individuals with Down syndrome, but higher levels than mothers of individuals with autism, although group differences varied somewhat across different dimensions of well-being. The most consistent predictor of maternal outcomes was the adolescent or young adult's behavioral symptoms.