Enhancing access to early intervention by including parent navigators with lived experience in a pediatric medical home

INTRODUCTION

A growing number of children have developmental delay (DD) or intellectual and developmental disabilities (IDD), and early intervention (EI) can improve their developmental trajectory. However, access to EI is fraught with disparities. This article describes the development of Parent Navigator (PN) program that placed three parents with lived experience in a pediatric medical home to serve as community health workers to provide support to families with a child with DD or IDD to access EI and other needed resources.

METHOD

We used a mixed-methods approach to program evaluation that included (a) documenting the number of referrals to the EI programs made by the PNs; (b) documenting referral outcomes; (c) conducting a physician satisfaction survey; and (d) interviewing the PNs to reflect on their experiences assisting families.

RESULTS

From July 2018 to September 2020, our PNs facilitated 623 referrals to EI due to significant developmental concerns found during a pediatric visit. Rates of successful connection to EI were 71%. Survey results indicated that pediatricians felt the PNs were a valuable part of the healthcare team and helped reduce their own job stress. The PNs provided multiple examples of their methods of addressing barriers to EI access by relating to families with their own lived experience and by "meeting families where they are at."

DISCUSSION

The PN program might be a successful approach to addressing disparities in EI access for families in need by using an innovative method of employing individuals with lived experience in the pediatric primary care setting. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Cute Kid? Patient Obesity Status and the Use of Nonmedical Descriptors in Presentations by Pediatric Residents

Nonmedical descriptors, adjectives that are not related to a medical condition, such as "cute," are often used in presentations in pediatrics. We hypothesize that patterns of their use may reflect obesity bias. Descriptors used by pediatric residents presenting cases of children <9 years in an outpatient clinic during the 2018-2019 and 2019-2020 academic years were recorded. The primary outcome was the association of the use of positive nonmedical descriptors with children's obesity status using logistic regression. Positive descriptors were used in 14% of 994 presentations. Most addressed the appearance of the child with variations of "cute" and "adorable." There was no variation in use of positive descriptors by obesity status. On multivariate logistic regression, the odds of using positive descriptors were higher among female residents, and positive descriptor use declined with patient age. Negative descriptors were rare and often focused on weight.

Pediatricians' role in healthcare for Latino autistic children: Shared decision-making versus "You've got to do everything on your own"

LAY ABSTRACT

Latino parents may choose to use complementary health approaches, such as vitamins, supplements, and special diets, for their autistic children. However, they might not tell their pediatrician about their complementary health approach use if they worry that the pediatrician will disapprove or judge them. This fear, along with pediatricians' lack of autism knowledge, creates barriers to "shared decision-making" between parents and pediatricians. Shared decision-making is a process where families and healthcare providers collaborate and exchange information in order to come to an agreement about treatment options. In our qualitative study with 12 bilingual Latino families of autistic children, we interviewed and observed families to learn about their experiences with both conventional healthcare (their pediatrician) and complementary health approaches. Our study results describe the parents' different pathways to an autism assessment, a process that is sometimes called the "diagnostic odyssey." The parents reported that conventional healthcare met their needs for their child's physical health but not for their child's developmental challenges. The parents who used complementary health approaches for their autistic children were more frustrated about a lack of autism information from pediatricians than those who did not use complementary health approaches. Finally, we describe two examples of successful shared decision-making between parents and pediatricians. We conclude that pediatricians who are able to talk about complementary health approaches with Latino families may help to facilitate shared decision-making and reduce healthcare disparities for Latino autistic children.

Using Community-Partnered Participatory Research to Value the "Community Lens" and Promote Equity in Community-Academic Partnerships

Background

Community input is crucial for identifying characteristics necessary for equitable, sustainable community-academic partnerships (CAPs). A November 2021 conference, honoring the late Dr. Loretta Jones and the Community-Partnered Participatory Research (CPPR) model, was held to gather input for designing a learning institute for community members as co-equal partners with academics in research, program, and policy initiatives. This created an opportunity to explore attendees' perspectives on challenges and opportunities related to CAPs with special focus on promoting equity.

Methods

Institutional Review Board approval was obtained. Five break-out discussion group sessions were conducted in November 2021 co-facilitated by both an academic and a community leader. After consent, discussions were recorded and transcribed. An iterative procedure for collaborative-group-thematic-analysis was developed. The six-phase process included rigorous coding, discussion, comparison of data with data, and development and refinement of themes and subthemes.

Results

A total of 38 racial-ethnically diverse participants volunteered from the total conference audience of 62 community and academic partners from various sectors including community-based organizations, health care, social services, academia, or policy within Los Angeles County. Analysis led to development of three themes: Being cautious with the extractive tendency of academia and the need for anti-racism within CAPs; Leveraging community power to resist the top-down lens of academia; and bridging two worlds through an equitably structured table.

Discussion

Participants described optimism about the future uses of CPPR to enhance CAPs, and the need to address barriers to equitable partnerships owing to unequal social contexts and entrenched power dynamics. Implications include addressing racism, evaluating financial equity in partnerships to promote accountability, and mentoring community leaders to promote equity.

Conclusion

Use of a "community lens" for developing sustainable, equitable CAPs is crucial to promote accountability and to responsibly implement authentic CPPR.

"She Is Stand-Offish Like That": Black Adults' Recognition of Child Behaviors Associated with Autism Spectrum Disorder

OBJECTIVE

The purpose of this study is to identify the sociocultural factors in the Black community that contribute to a delay in identification of Black children with autism spectrum disorder (ASD).

METHODS

Four focus groups with parents of typically developing children were conducted at 2 Black Churches using a community-partnered participatory research approach and the socioecological model. Participants completed sociodemographic surveys, viewed CDC Autism Training Videos of Black children with ASD, and reported on their behavioral observations. Focus groups were audio recorded and transcribed. Thematic data analysis was conducted using NVivo software.

RESULTS

At the individual level, participants interpreted ASD-associated behaviors as a problem of timing of developmental milestones in the course of normative development rather than a sign of a disorder and positive and negative characteristics. At the interpersonal level, the role of grandparents and extended family was important for monitoring child development. At the organizational level, racial concordance with health care providers was seen as critical because of historical mistrust. At the community level, fear of racism and child protective services and inequitable care emerged. At the policy level, there were concerns about access to affordable, high-quality care.

CONCLUSION

This study provides insight into the sociocultural factors in the faith-based Black community that may contribute to a delay in identification of Black children with ASD. Health care professionals need additional training to effectively serve Black children and families in the face of historical mistrust and health care inequity.

Not just at school: Inclusion of children with autism spectrum disorder in a weight management program in a community pediatric setting

LAY ABSTRACT

Children diagnosed with autism are likely to be more overweight than children who do not have autism. There are many group programs that help children to be more physically active and improve their eating habits to achieve healthy weight, but most of these programs do not allow children with autism to participate. We studied a program that was specially adapted so children with autism could participate together with peers who do not have autism. The program lasted 8 weeks and was offered in the evening at a large healthcare center in a big city. The children participated with a parent or another adult who takes care of them. We analyzed data that were part of a previous project where we studied how physical activity trackers called Fitbit help overweight children to change their eating and exercise habits so they can achieve healthier weight. Out of 158 families in the study, 15 families had a child or children with autism. We measured changes in the weight of children with and without autism and compared how many of the children completed the program. Children who had autism had similar results in achieving healthy weight and finishing the program compared to their peers without autism. Our study found that when a group weight management program is slightly changed to meet the needs of children with autism, they can successfully participate and benefit similarly to their peers who do not have autism.

REGISTRATION

This trial was registered with ClinicalTrials.gov (NCT03215641).

Sex Differences in Co-occurring Conditions Among Autistic Children and Youth in Florida: A Retrospective Cohort Study (2012-2019)

Autistic children have a high prevalence of co-occurring mental health, developmental/behavioral, and medical conditions, but research on sex/gender differences has been mixed. We used Florida healthcare claims data to characterize sex differences (female/male) in co-occurring conditions among autistic children ages 1-21 (N = 83,500). After adjusting for age, race, ethnicity, urbanicity, and insurance, autistic girls had significantly higher odds of anxiety disorders, mood disorders, intellectual disability, developmental disorders, epilepsy, metabolic disorders, gastrointestinal disorders, and sleep disorders compared to autistic boys. Autistic girls had significantly lower odds of ADHD. The findings contribute to the growing body of research on the unique healthcare needs of autistic girls.

Racial and Ethnic Differences in Behavioral Problems and Medication Use Among Children With Autism Spectrum Disorders

We examined racial and ethnic differences in the prevalence of behavioral problems measured by the Child Behavioral Checklist (CBCL), sleep disturbances measured by the Child Sleep Habits Questionnaire (CSHQ), and medication use among children with Autism Spectrum Disorders (ASD). We analyzed data from the Autism Treatment Network (ATN) dataset for 2,576 children ages 6 to 18 years of age diagnosed with ASD. Multivariable logistic regression accounting for age, gender, Diagnostic and Statistical Manual of Mental Disorders (4th Edition - Text Revision), diagnosis (Autistic Disorder, PDD-NOS, Asperger's Disorder), and parents' education did not show any racial or ethnic differences in behavioral challenges, conduct problems, or sleep disturbances for any of the groups, but Black children had lower odds of Total Problem Behaviors and Asian children had lower odds of Hyperactivity compared to White children. As a group, children from racial and ethnic minorities had lower odds of Total Problem Behaviors and Conduct Problems compared to White children. Hispanic children had lower odds of medication use for Behavioral Challenges, Total Problem Behaviors, Hyperactivity, and Conduct Problems. Asian children had lower odds of medication use for Behavioral Challenges, Total Problem Behaviors, and Hyperactivity; and had close to lower odds in medication use for Conduct Problems. Black children had lower odds for medication use for Total Problem Behaviors only. As a group, children from racial and ethnic minorities had lower odds for medication use for Behavioral Challenges, Total Problem Behaviors, Hyperactivity, and Conduct problems, but not for Sleep Disturbances. While these results are consistent with previous studies showing that White children are significantly more likely to receive psychotropic medication compared to children from racial and ethnic minority groups, we found no such differences for sleep challenges, suggesting that they are more consistently identified and equitably treated than other behavioral problems associated with ASD. We draw upon Andersen's (1995) Behavioral Model of Healthcare Use to suggest predisposing, enabling, and needs factors that may contribute to this pattern of racial and ethnic differences in the use of medications among children ASD.

Racial/ethnic minority children recently placed in the child welfare system: the impact of sociodemographic, medical and mental health factors on overweight /obesity

Children in the child welfare system have greater rates of obesity and are more prone to overweight/obesity as adults compared to other children. There is limited research on how ecological, biological and developmental factors impact the trajectory of overweight/obesity in this group. This retrospective study examined these factors among children entering the child welfare system. Overweight/obesity was highest among children 12-18 years. Children with diagnoses indicative of poor nutrition, and limiting exercise, were more likely to be overweight/obese. Ecological risks often were not disclosed. Barriers to obtaining information to address overweight/obesity reflect challenges to addressing chronic disease more broadly.

'When the dog bites': What can we learn about health geography from newspaper coverage in a 'model city' for dog-bite prevention?

Despite calls for the adoption of 'One-Health' approaches, dog-bite injuries remain neglected in healthcare and public health, and our study may help to understand why. Media coverage can influence policy directions, including policies that address dogs. We collected articles (n = 65) published in two local newspapers, 2012-2017, then carried out an ethnographically-informed discourse analysis of the dog-bite reports. The newspapers portrayed dog-bites mainly as matters of public disorder, as opposed to priorities for healthcare and public health. Even as our study took place in a city that has shown dog-bite reductions without recourse to 'breed bans' or restrictions (i.e., breed-specific legislation), journalists still tended to emphasize dog breed as a narrative element in explaining dog-bite incidents. Nonetheless, the news coverage did not reproduce a 'nature versus nurture' dichotomy. Rather, the journalists presented dog breed, and presumably associated aggressive behaviour, as entanglements with social, economic, and cultural contexts. Meanwhile, the news stories reduced contextual complexity to geographic locations, as codes for community reputation, in attributing causality and morality.

Early Childhood Obesity Among Underserved Families: A Multilevel Community-Academic Partnership

A community-academic partnership, based on a social-ecological framework, addressed pediatric obesity by implementing a multilevel intervention for underserved families in Los Angeles, California. Individual- and interpersonal-level outcomes included significant positive changes in preschoolers' identification of unhealthy foods and in parents' shopping, cooking, and parenting behaviors. Organizational-, community-, and policy-level outcomes included healthy options at restaurants and a coalition supporting a parental initiative to create healthy checkout aisles in supermarkets. The multilevel intervention demonstrated favorable results using descriptive statistics and the paired-samples t-test.

Beyond V40.31: Narrative Phenomenology of Wandering in Autism and Dementia

Research on autism spectrum disorder (ASD) and on Alzheimer's Disease (AD) and other types of dementia describes a behaviour called 'wandering', a term that denotes movement through space lacking intention or exact destination, as when a person is disoriented or not self-aware. In the U.S., 'wandering' in both ASD and AD has been examined mostly from a management and prevention perspective. It prioritizes safety while primarily overlooking personal experiences of those who 'wander' and their families, thus limiting the range of potentially effective strategies to address this issue. Communicative challenges faced by many people diagnosed with ASD and AD further obscure the experiential, existential aspects of 'wandering'. This article reflects an increasing concern of social science scholars interested in whether and how the conceptual and practical strategies to address 'wandering' are informed by the situated experiences of people with cognitive and developmental disabilities and their families. We examine 'wandering' at the intersections of personal experience, family life, clinical practice, public health policy, and legislation, as a conceptually rich site where notions of personhood, subjectivity, intentionality, and quality of life powerfully and consequentially converge to impact the lives of many people with ASD and AD, and their families. We draw upon critical autism studies describing how attributions of personhood, subjectivity, intentionality, rational agency, and moral autonomy of people with ASD have been contingent upon the norms and conventions governing movement of the human body through space (Hilton, Afr Am Rev 50(2):221-235, 2017). When this movement is deemed aberrant, the person may be construed as irrational, a danger to self because of a lack of self-awareness, and a danger to others because of a lack of empathy. These attributions put the person at risk of being excluded from the considerations and, more importantly, the obligations of the 'moral community' to ensure that he or she has a 'good human life' (Barnbaum, The Ethics of Autism: Among Them but not of Them. Indiana University Press, Bloomington, 2008; Silvers and Francis, Metaphilosophy 40(3/4):475-498, 2009). Using ethnographic, narrative phenomenological (Mattingly, The Paradox of Hope: Journeys through a Clinical Borderland. Berkeley: University of California Press, 2010), and medical humanities (Charon, JAMA 286:1897-1902, 2001; Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press, 2006) approaches, we examine multiple perspectives on 'wandering' in ASD and AD across narrative discourse genres, institutional contexts, and media of representation. We argue for an extension of the prevention and management view to focus not only on safety but also on what phenomenologist Merleau-Ponty (1962) called "having a world" (p. 146). The analysis is intended to inform clinical practice, policy and public health efforts to enhance understanding of first and second person perspectives on 'wandering' in order to improve the participation and quality of life of people with ASD and AD who 'wander', and their families.

'If I was a different ethnicity, would she treat me the same?': Latino parents' experiences obtaining autism services

This article reports on an ethnographic study with 12 Latino families of children on the autism spectrum related to obtaining autism services in Los Angeles County. Using critical discourse analysis of interviews, observations, and records, we consider the experiences of the Latino families in relation to: 1) A discursively constructed 'autism parent' subject position that mandates 'fighting' service systems to 'win' autism services for children, originating from White middle-class parents' socio-economic resources and social capital; 2) A neoliberal social services climate that assumes scarcity of available resources and prioritizes austerity in their authorization; and 3) A media and institutional 'cultural deficit' discourse that attributes disparities in autism services for Latino children to their parents' presumed culturally-based 'passivity.' We argue that parental discourse about fighting, or not fighting, for autism services is engendered by a tension between a parental logic of care, and the logic of competition of the economic market.

Understanding parents' concerns about their children with autism taking public school transportation in Los Angeles County

There are a number of recent US news media reports of children and youth with autism becoming lost, injured, or even dying while taking public school transportation, yet research on this problem is scarce. This ethnographic study examines the experiences of 14 parents whose children with autism take public school transportation in Los Angeles County. We present two case studies of children with autism being "lost" while in transit from school to home on the bus to (1) describe how the situation was experienced, responded to, and managed by the parents; (2) consider three interrelated themes that emerged from interviews with 14 parents, related to children's safety, independence, and participation, across multiple contexts and analytic levels; and (3) discuss the findings in relation to US news media reports of incidents involving children with autism on school buses to identify specific weaknesses in school transportation infrastructure, particularly in the context of privatization, that create conditions in which children with autism can "fall through the cracks" in potentially life-threatening ways. We argue that there is a critical need to address transportation accessibility for individuals on the autism spectrum to ensure their safety and support their independence and community participation.

Latino Families' Experiences With Autism Services: Disparities, Capabilities, and Occupational Justice

This article examines six cases of publicly funded Applied Behavior Analysis (ABA) therapy for Latino children with autism spectrum disorder (ASD) to contribute to thinking about occupational justice. In this ethnographic study of six Latino families of children with ASD in Los Angeles County, all families were offered ABA for their children, but five families experienced occupational challenges leading them to insist on modifications of ABA or to opt out of the service. We consider in each case (a) how the families' experiences can be understood occupationally, (b) how ABA affected the functionings and capabilities of the children and their families, and (c) how the parents' accounts relate to occupational justice. Applying the capabilities approach can help operationalize the concept of occupational justice as a tool to evaluate social policy across cases.

‘What Brings Him Here Today?’: Medical Problem Presentation Involving Children with Autism Spectrum Disorders and Typically Developing Children

Conversation and discourse analyses were used to examine medical problem presentation in pediatric care.Healthcare visits involving children with ASD and typically developing children were analyzed. We examined how children’s communicative and epistemic capabilities, and their opportunities to be socialized into a competent patient role are interactionally achieved. We found that medical problem presentation is designed to contain a ‘pre-visit’ account of the interactional and epistemic work that children and caregivers carry out at home to identify the child’s health problems; and that the intersubjective accessibility of children’s experiences that becomes disrupted by ASD presents a dilemma to all participants in the visit. The article examines interactional roots of unmet healthcare needs and foregone medical care of people with ASD.

Does the Company of a Dog Influence Affective Response to Exercise? Using Ecological Momentary Assessment to Study Dog-Accompanied Physical Activity

Purpose:

This study used ecological momentary assessment (EMA), a real-time self-report strategy, to examine (1) whether dog owners were more likely to be physically active when they were with their dogs and (2) whether being with a dog amplifies positive and dampens negative affective response during physical activity.

Design:

Electronic EMA surveys for 12 days.

Setting:

Free-living.

Participants:

Seventy-one adult dog owners.

Measures:

The EMA survey included 1 question about current activity, 3 questions about positive affect (Cronbach α = .837), 4 questions about negative affect (Cronbach α = .865), and 1 question about the presence of dog.

Analysis:

Multilevel modeling.

Results:

The company of a dog did not increase the likelihood of being active versus sedentary at any given EMA prompt. However, greater positive affect during physical activity was reported in the company of a dog. Negative affect did not differ between active and sedentary activity, regardless of being with a dog or not.

Conclusion:

This study demonstrates the utility of electronic EMA as a promising methodology to study dog-accompanied physical activity. Future studies may use EMA to collect further contextual information about dog-accompanied activity to inform the development of innovative physical activity interventions.

Methodological Challenges in Examining Family and Child Perspectives on Lived Experiences of Disability in Daily Life

Date Presented 4/7/2016

The authors discuss the salience of family and child perspectives, conceptualization of study design, methodological innovations designed to elicit data related to lived experiences, scientific rigor, analytic approaches, and moral dilemmas.

Primary Authors and Speakers: Mary Lawlor, Olga Solomon

"You Can Turn off the Light If You'd Like": Pediatric Health Care Visits for Children with Autism Spectrum Disorder as an Interactional Achievement

Substantial scholarship has been generated in medical anthropology and other social science fields on typically developing child-parent-doctor interactions during health care visits. This article contributes an ethnographic, longitudinal, discourse analytic account of a child with autism spectrum disorder (ASD)-parent-doctor interactions that occur during pediatric and neurology visits. The analysis shows that when a child with ASD walks into the doctor's office, the tacit expectations about the visit may have to be renegotiated to facilitate the child's, the parent's, and the doctor's participation in the interaction. A successful visit then becomes a hard-won achievement that requires the interactional and relational work of all three participants. We demonstrate that communicative and sensory limitations imposed by ASD present unique challenges to all the participants and consider how health care disparities may invade the pediatric encounter, making visible the structural and interactional processes that engender them.

Health Care Disparities and Autism: Analytic Approaches to Understanding Families’ Experiences in Their Everyday Lives

Date Presented 4/17/2015

In this research, we examine health care disparities linked to autism as situated around particular everyday problems encountered by families: negotiations of expertise, management of elopement and wandering, and acquisition of an autism diagnosis. Research, practice, and policy implications are discussed.

The social life of health records: understanding families' experiences of autism

Outside of the epidemiological surveillance studies of autism prevalence, health records of children diagnosed with autism have not been sufficiently examined, yet they provide an important lens for showing how autism diagnosis, services and interventions are negotiated, coordinated and choreographed by families and practitioners across multiple settings. This article provides a multifaceted understanding of these processes from an ethnographic and discourse analytic perspective that reveals structural and interactional phenomena contributing to disparities in autism diagnosis and services. We consider health records as dualistic, material-discursive artifacts that are socio-interactionally co-constructed and variably interpreted, contested and utilized across home, school and clinic contexts. We chronicle several families' experiences of their children's autism diagnoses and interventions and describe ways in which health records are socially constructed, curated and placed in the middle of clinical encounters. We show how the parents in our study draw upon health records' material-discursive properties to display epistemic authority, expertise and knowledge in interactions with healthcare and school professionals involved in authorizing and planning their children's care. We describe how the parents experience the health records' clinical portrayals of their children and themselves, and how the parents' portrayals of their children are tacitly ratified or negated in the health records. The data include health record reviews, narrative interviews with parents and practitioners, and clinical observations. These data were collected between October 2009 and August 2012 as part of a larger study on disparities in autism diagnosis, interventions and services experienced by African American children with autism and their families living in Los Angeles County, California. Our analysis reveals the central role of health records in maintaining continuity of an autism diagnosis, interventions and services. This article contributes to enhanced professional awareness, parent-professional partnerships, and equity in the provision of healthcare and human services related to autism.

"And I look down and he is gone": narrating autism, elopement and wandering in Los Angeles

'Wandering' and 'elopement' have been identified as common in autism, affecting half of all diagnosed children ages four to ten, yet families rarely receive advice from practitioners even after the fact. Family perspectives have been missing from the literature as well as from public health and policy debates on how and when to respond to this problem. The problem of 'wandering' and 'elopement' reveals a complex intersection of larger issues encountered by families of children with autism. To consider these issues, this article examines 'wandering' and 'elopement' from the perspectives of African American mothers of children with autism, an underrepresented group in autism research. We consider how the mothers experience these behaviors and the response to these behaviors by professionals, such as service coordinators and law enforcement personnel working within various jurisdictions that become involved with the problem. We analyze the mothers' narratives about 'wandering' and 'elopement' drawn from ethnographic interviews that were collected between October 1, 2009 and August 31, 2012. These interviews were part of a larger project on disparities in autism diagnosis and services that followed a cohort of 25 four to ten-year old children. Drawing on narrative, phenomenological and interpretive traditions, we trace the mothers' developing understandings of 'wandering' and 'elopement' over time, and show how these understandings become elaborated and transformed. This article provides a nuanced, moment-to-moment and longitudinal picture of the mothers' experiences of 'wandering' and 'elopement' that enriches the cross-sectional view of large-scale surveys about the problem and contributes unique insights at the family and community levels. Implications for professional awareness, clinical practice and service provision are also suggested.

Sense and the Senses: Anthropology and the Study of Autism

As a clinical category and a sociocultural phenomenon, autism occupies a prominent albeit ambiguous place in ongoing social science and humanities debates about empathy, intersubjectivity, intentionality, epistemological certainty, and moral agency. Autism is used as a counterexample to feeling empathy and understanding other people's beliefs and intentions. Alternatively, it is given as evidence of the limitless potential and neurodiversity of the human mind. This review examines the field of autism research relevant to anthropology of the senses. It considers the production of knowledge about autism as a clinically relevant category at the intersection of sense as culturally organized competence in meaning making and the senses as a culturally normative and institutionally ratified sensory and perceptual endowment. In such a distinction, both sense and the senses are paths toward and objects of the empirical understanding of autism.