Cost Offset Associated With Early Start Denver Model for Children With Autism

Accuracy of the Screening Tool for Autism in Toddlers and Young Children in the primary care setting

Feasible and accurate assessment tools developed for non-specialists are needed to scale community-based models of autism evaluation. The purpose of this study was to evaluate use of the Screening Tool for Autism in Toddlers and Young Children (STAT) when used by primary care practitioners (n = 10) across a statewide system of early diagnosis set within seven United States primary care practices. Specifically, for 130, 14- to 48-month-old children, we examined (1) agreement between STAT classification and Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) outcome and expert diagnosis of autism, (2) characteristics of children with inaccurate STAT classifications, (3) consistency between STAT classification and primary care practitioner diagnosis, and (4) the relationship between STAT/primary care practitioner classification and expert diagnosis. The STAT demonstrated good concurrent validity with the ADOS-2 (77% agreement). Concordance between specialty trained primary care practitioners with expert diagnosis was 80%-87% across three age-based subgroups of children. Children misclassified by the STAT were older, had higher developmental and adaptive skills, and lower autism symptoms. Primary care practitioner diagnosis aligned with STAT categorical risk classification in 86% of cases, and 73% of consistent classifications between STAT and primary care practitioner diagnosis matched expert diagnosis. Overall, the STAT demonstrates good accuracy when used by non-specialists as part of a diagnostic evaluation.Lay summarySpecialists conduct autism evaluations using tools that are expensive and difficult to get trained on. Families often wait a long time and travel far to get a diagnosis for their child. To help with this problem, primary care practitioners can be trained to provide evaluations in local communities. However, usable and accurate tools developed for non-specialists are needed. The Screening Tool for Autism in Toddlers and Young Children (STAT) was created for this purpose, but limited research has been done on accuracy of the tool in community primary care. This study tested the STAT when used by primary care practitioners as part of a diagnostic evaluation in 130, 14- to 48-month-old children. We tested (1) STAT agreement with the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), and diagnosis based on an expert research evaluation, and (2) the relationship between STAT classification, primary care practitioner diagnosis, and expert diagnosis. STAT classification matched the ADOS-2 in 77% of cases and expert diagnosis in 78% of cases. Autistic children incorrectly classified by the STAT were older, had higher developmental and adaptive skills, and fewer autism symptoms. In 86% of cases, the STAT classification agreed with primary care practitioner diagnosis. STAT classification, primary care practitioner diagnosis, and expert diagnosis agreed in 73% of cases. Overall, the STAT shows good accuracy when used by primary care practitioners as part of a community primary care autism evaluation.

Parental Demand, Learning, and Satisfaction With Virtual Parent Coaching of Music Interventions

Virtual music therapy services became common during the COVID-19 pandemic and have remained a viable option for communities with access barriers. Parent coaching is a specific intervention where primary caregivers learn evidence-based strategies to support their children's development. Virtual music parent coaching has initial evidence of feasibility for families of autistic children. In this study, we used quantitative and qualitative measures to evaluate an 8-week parent coaching program. Feasibility aspects included parental demand, retention, learning, and satisfaction, interventionist's fidelity to the coaching program, and primary caregiver perspectives of outcomes, challenges, and benefits. Results indicated that caregivers learned about the research opportunity mainly through social media, with much lower response to email invitations. Eleven participants enrolled in the study, but 7 completed the program, for a 64% retention rate. Main reasons to drop out were time constraints and other responsibilities. Parents reported a high level of satisfaction and appropriate learning, as well as meaningful changes in their child's communication, understanding their child better, and valuing the accessibility and flexibility of the virtual modality. An interventionist with limited specialized training in autism but appropriate clinical experience achieved fidelity in the parent coaching model quickly. Caregivers' recommendations for improvement included providing recorded examples of the music and tailoring the written materials to each family. Suggestions for future research and practice include prioritizing social media as recruiting medium, evaluating parental disposition and time availability before initiating the program, considering siblings' needs, investigating cost effectiveness, and emphasizing the interventionist's collaborative approach with the parent.

Characteristics of Young Children Associated with Diagnostic Utility of the Autism Diagnostic Observation Schedule: A DBPNet Study

OBJECTIVE

The aim of this study is to identify characteristics of children for whom a developmental-behavioral pediatrician's (DBP) diagnostic impressions of autism spectrum disorder (ASD) or non-ASD were changed by Autism Diagnostic Observation Schedule (ADOS) results.

METHOD

A prospective study of children 1½ to <6 years consecutively referred to 8 sites for possible ASD. Cognitive/developmental, language, and adaptive testing varied, as each site followed its usual clinical approach. DBPs documented diagnosis as ASD or non-ASD and their degree of diagnostic certainty (1-10) pre- and post-ADOS. Cases where DBP diagnostic impression did not change after ADOS administration ("Stable Group," n = 314) were compared with those for whom it did change ("Changed Group," n = 35), followed by matched random sample comparisons.

RESULTS

There were no significant differences in child characteristics (age, gender, race, ethnicity, insurance, caregiver education) between the Stable and Changed groups. DBPs' diagnostic certainty was significantly lower, both pre- and post-ADOS, in the Changed versus Stable group. Change was associated with milder symptoms of ASD and less impaired language. In an age- and gender-matched comparison, significant differences remained for diagnostic certainty and severity of social communication impairments. Cognitive scores were significantly higher in the Changed Group. Because of significantly higher caregiver education and a trend toward more privately insured children among the Changed Group, samples (n = 35 each) were then matched on those characteristics, revealing the same differences for diagnostic certainty, severity of ASD symptoms, and language skills.

CONCLUSION

Young children with milder ASD symptoms and less impaired language may benefit most from the administration of the ADOS.

Initial Validation of the Mandarin Translation of the Stanford Social Dimensions Scale (SSDS)

This study aimed to validate the Mandarin translation of the Stanford Social Dimensions Scale (SSDS). The initial validation sample consisted of 480 children with Autism Spectrum Disorder (ASD) (Mage = 9.35). Discriminant validity was appraised by comparing relevant SSDS scores among samples of children with ASD, typical development (TD) (N = 160, Mage = 7.16), and non-ASD but Neurodevelopmental Disorders (NDDs) (N = 170, Mage = 5.08). Confirmatory application of the Exploratory Structural Equation Modelling indicated that a five-factor model encompassing Social Motivation (SM), Social Affiliation (SA), Expressive Social Communication (ESC), Social Recognition (SR) and Unusual Approach (UA) provided adequate to excellent fit to the data in ASD group ([CFI] = .908, [TLI] = .930, [RMSEA] = .052, [SRMR] = .028). The factor loadings of most items constituting SM, SA, ESC, and SR factors were aligned with the original factor structure in the US sample, except items on the UA factor that showed lower loadings. The internal consistency was .93-.96, and test-retest reliability was .86. Discriminate validity was excellent, with the ASD group showing significantly lower scores compared to non-ASD NDDs and TD groups. Convergent and divergent validity of the SSDS was strong, as indexed by the pattern of correlations with relevant Social Responsiveness Scale, second edition (SRS-2), and Social Communication Questionnaire (SCQ) domains. This study provided preliminary validation of the Mandarin translation of the SSDS by largely replicating the original factor structure and showing evidence for strong discriminant, convergent, and divergent validity. Potential areas where further refinement and potential expansion of the SSDS are needed were identified.

Training and Sustaining: Training and Learning Collaborative Outcomes Across a Statewide Network for Early Autism Diagnosis

OBJECTIVE

The objective of this study was to describe the development of a primary care professional (PCP) autism diagnosis training model and to report on outcomes related to PCP training and sustained engagement in a longitudinal learning collaborative.

METHODS

We developed Accelerating the Diagnosis of Autism with Primary care Training (ADAPT), a training program to prepare PCPs to develop independent competency in evaluation of autism in children aged 14 to 48 months. ADAPT includes didactic and case-based modules and practice-based coaching delivered by an expert diagnostic specialist; after training, PCPs participate in a longitudinal learning collaborative. Aligned with competency-based medical education standards, measures of autism evaluation knowledge and diagnostic competency are collected.

RESULTS

From 2021 to 2023, 13 PCPs completed ADAPT didactic and practicum training to reach competency in independent autism evaluation. Clinicians demonstrated significant improvement in total autism knowledge after didactic training ( p = 0.02). Scoring agreement on an autism observational assessment tool between clinicians and expert diagnosticians improved over case observations and practicum evaluations. Similarly, PCPs demonstrated improved evaluation competence, moving on average from Advanced Beginner to Competent Performer as rated by expert diagnosticians. After training, PCPs attended 57% of monthly learning collaborative sessions.

CONCLUSION

Training PCPs to deliver autism evaluations for young children as part of tiered community-based models of care is a promising solution to address access and waitlist challenges. ADAPT is an intensive, standardized PCP training model that results in achievement of independent competency and sustained engagement in autism evaluation. Effectiveness-implementation studies are needed to ensure scalability and sustainability of training models.

Internal Consistency of the Serbian Translation of the Stanford Social Dimensions Scale and Association to Strengths and Difficulties Questionnaire Scores in Male and Female Individuals on the Autism Spectrum and Non-autistic Individuals

We aimed to evaluate the internal consistency of Stanford Social Dimensions Scale (SSDS) translated to Serbian and to test it against the Strengths and Difficulties Questionnaire (SDQ). The sample consisted of 200 patients (32% ASD) of the Institute of Mental Health in Belgrade, Serbia (68 females, 132 males, Mage=9.61, SDage=4.06). Internal consistency coefficients were within good/acceptable range for Social Motivation, Affiliation, Recognition and Unusual Approach subscales and below acceptable for Expressive Social Communication subscale. The non-autistic group scored higher on all subscales compared to the ASD group. All SSDS subscales positively correlated with SDQ Prosocial Behaviors scale. The SSDS is a valuable instrument for accessing sociobehavioral phenotype in both individuals on the autism spectrum and non-autistic individuals.

Using Causative Methods to Determine System-Level Factors Driving the Uptake and Use of Evidence-Based Practices in a Public Early Intervention System

Part C Early Intervention (EI) systems are an entry point to services for autistic toddlers and can be leveraged to facilitate access to autism evidence-based practices (EBPs). However, EI systems are complex and limited research has examined how an EI system's infrastructure (i.e. system-level factors) impacts the adoption and implementation of EBPs. To address this gap, 36 EI providers and 9 EI administrators completed a semi-structured interview or focus group about factors impacting the implementation of autism EBPs. Qualitative analysis included a combination of grounded theory and causative coding. Analyses were refined by input from providers, administrators, and family stakeholders in the form of round tables and presentations at the state's interagency coordinating council. Primary themes centered on: (1) the costs associated with independent contracting structures; (2) operational demands; (3) workforce stability; (4) communication consistency; and (5) implementation supports for EBP implementation. Causative coding helped to demonstrate the perceived relationships between these factors and underscored the important role of incentivization structures, collaboration opportunities, and championing in supporting the use of EBPs within a system that primarily uses independent contracting structures. The current study extends previous research by demonstrating how several system-level factors are perceived to play a role in the adoption and implementation of EBPs by independently contracted EI providers. These findings underscore the need for implementation strategies, such as incentivization strategies and social network building, to increase providers' implementation of autism EBPs within EI systems.

Eye-Tracking Biomarkers and Autism Diagnosis in Primary Care

Importance

Finding effective and scalable solutions to address diagnostic delays and disparities in autism is a public health imperative. Approaches that integrate eye-tracking biomarkers into tiered community-based models of autism evaluation hold promise for addressing this problem.

Objective

To determine whether a battery of eye-tracking biomarkers can reliably differentiate young children with and without autism in a community-referred sample collected during clinical evaluation in the primary care setting and to evaluate whether combining eye-tracking biomarkers with primary care practitioner (PCP) diagnosis and diagnostic certainty is associated with diagnostic outcome.

Design, Setting, and Participants

Early Autism Evaluation (EAE) Hub system PCPs referred a consecutive sample of children to this prospective diagnostic study for blinded eye-tracking index test and follow-up expert evaluation from June 7, 2019, to September 23, 2022. Participants included 146 children (aged 14-48 months) consecutively referred by 7 EAE Hubs. Of 154 children enrolled, 146 provided usable data for at least 1 eye-tracking measure.

Main Outcomes and Measures

The primary outcomes were sensitivity and specificity of a composite eye-tracking (ie, index) test, which was a consolidated measure based on significant eye-tracking indices, compared with reference standard expert clinical autism diagnosis. Secondary outcome measures were sensitivity and specificity of an integrated approach using an index test and PCP diagnosis and certainty.

Results

Among 146 children (mean [SD] age, 2.6 [0.6] years; 104 [71%] male; 21 [14%] Hispanic or Latine and 96 [66%] non-Latine White; 102 [70%] with a reference standard autism diagnosis), 113 (77%) had concordant autism outcomes between the index (composite biomarker) and reference outcomes, with 77.5% sensitivity (95% CI, 68.4%-84.5%) and 77.3% specificity (95% CI, 63.0%-87.2%). When index diagnosis was based on the combination of a composite biomarker, PCP diagnosis, and diagnostic certainty, outcomes were concordant with reference standard for 114 of 127 cases (90%) with a sensitivity of 90.7% (95% CI, 83.3%-95.0%) and a specificity of 86.7% (95% CI, 70.3%-94.7%).

Conclusions and Relevance

In this prospective diagnostic study, a composite eye-tracking biomarker was associated with a best-estimate clinical diagnosis of autism, and an integrated diagnostic model including PCP diagnosis and diagnostic certainty demonstrated improved sensitivity and specificity. These findings suggest that equipping PCPs with a multimethod diagnostic approach has the potential to substantially improve access to timely, accurate diagnosis in local communities.

Pediatrician and parental evaluation of child neurodevelopment at 2 years of age

BACKGROUND

The early identification of infants with a risk for neurodevelopmental disorders in the first few years of life is essential for better developmental outcomes. Screenings should be carried out by combining the family pediatricians' and parents' perspectives, the two fundamental sources of information on children's health. The present study has three aims: (a) to test the feasibility of parent-report instruments to detect warning signs in their children's development; (b) to ascertain whether there is an agreement between the family pediatricians' (FP) clinical judgments of warning signs and the parental perceptions; (c) to determine whether there is a link between parents' distress and child development.

METHODS

Within the NASCITA birth cohort, in addition to the family pediatrician's clinical evaluation with routine tools, the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) was completed by parents to assess the child's language, social skills, behavior, and sensory areas. Parents were also asked to complete the Parenting Stress Index, Short Form (PSI-SF) to verify the magnitude of stress in the parent-child system. Univariate and multivariate analyses were performed to evaluate the association between child and parental characteristics and the presence of warning signs.

RESULTS

The follow-up assessment was completed for 435 infants: 69 (15.8%) presented warning signs: 43 in the pediatrician's assessment and 36 in the M-CHAT-R (10 in both). A total of 16 children (14 with warning signs) received a diagnosis after a specialist evaluation. Being male (OR 2.46, 95%CI: 1.23-4.91) and having sleep disorders (OR 2.43, 95% CI 1.17-5.04) was associated with a greater likelihood of warning signs in the multivariate analysis, while reading aloud was a protective factor (not exposed versus exposed (OR = 3.14; 95% CI 1.60-6.17). For 73 children (18.4%), at least one parent tested positive for PSI-SF. An increased prevalence of parental distress was observed in children with warning signs (OR 2.36, 95% CI 1.27-4.37).

CONCLUSIONS

Integrating physician and parental perspectives during well-child visits and in clinical practice appears feasible and can improve the identification of children at risk of developmental disorders.

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

BACKGROUND

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

OBJECTIVES

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

METHODS

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

RESULTS

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

CONCLUSION

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

TRIAL REGISTRATION

NCT05551728 in Clinical Trial Registry (https://clinicaltrials.gov).

Unraveling the Role of Neuroligin3 in Autism Spectrum Disorders: Pathophysiological Insights and Targeted Therapies

Autism Spectrum Disorder is a neurodevelopmental disorder characterized by impaired social and communication skills, repetitive behaviors, and/or restricted interests with a prevalence of as high as 1% of children. Autism spectrum has strongly associated with genetic factors and exhibits wide clinical and heterogeneous genetic architecture. Most genes associated with Autism are involved in neuronal and synaptic development. The neuroligin3, the sex-linked gene on the X chromosome, was the first gene to be associated with a monogenic form of Autism. Neuroligin3 is a postsynaptic cell adhesion protein involved in synapse transmission, brain formation, and neuronal development. In this review, we provide recent findings on different mutations in the Neuroligin3 gene linked to Autism spectrum disorder and their molecular pathway effect. We also give the behavioral, and synaptic alterations reported in the Neuroligin3 animal model of Autism and the potential therapeutic strategies targeting the biological processes and the main symptoms of autism spectrum disorder. In addition, we discuss the use of novel technologies like induced pluripotent stem cells from Autistic patients that have the potential to differentiate in human neurons and therefore have a variety of applications in therapy and biomedical studies to search specific biomarkers, and develop systems for screening chemical molecules in human cells to discover target therapies.

Policies for Individuals With Autism: Gaps, Research, and Recommendations

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder characterized by social, behavioral, and learning challenges. Individuals with autism and their families often struggle to get an appropriate diagnosis and continuation of specialty services, including general healthcare, mental health and transition services, special education, employment, and social and emotional support. This paper presents information about the current policies and support mechanisms that exist to help these individuals and their families. This paper identifies the gaps and recommends areas of improvement based on evidence-based research and current data. ASD is a lifelong disability without a cure, but by constructing robust policies and providing enhanced support, the quality of lives of those with ASD and their families can be improved.

Working memory training in autism: Near and far transfer

INTRODUCTION

The autistic population is expanding. It is generally recognized that executive function deficits (EFs) are at the core of this disorder. Working memory (WM) is considered a critical element in executive functioning. WM training is regarded as a promising new therapy that can improve EFs and reduce symptoms of autism by targeting WM through repetitive exercises.

AIM

To investigate the impact of WM training on WM, cognitive flexibility, planning, and clinical symptoms. Also, to examine whether age influences the remediation effects.

METHODS

Only one group of 20 verbal autistic participants aged 6 to 21 years was included. They received 40 training sessions. The program used is called "Cogmed". Neuropsychological measures were administered before and after the intervention to assess the three EFs. The Social Communication Questionnaire (SCQ) was exploited to evaluate its effects on clinical symptoms.

RESULTS

Only 17 participants have completed the training. They showed significant and large improvements in WM subtests (p<0.01, η^2>0.06), cognitive flexibility (p<0.05, η^2>0.06), planning (p<0.01, η^2 >0.06), and symptoms (p<0.01, η^2 >0.06). Also, the ANOVA test revealed that the age and the intervention effects are not correlated in our sample (p >0.05).

CONCLUSION

WM training influences EFs positively in autism and reduces the severity of its clinical characteristics. Thus, it's an effective therapy that can be added to the management of this disorder.

Effects of Parent-Implemented Interventions on Outcomes of Children with Autism: A Meta-Analysis

Children with autism spectrum disorder (ASD) have been shown to benefit from parent-implemented interventions (PIIs). This meta-analysis improved on prior reviews of PIIs by evaluating RCTs and multiple potential moderators, including indicators of research quality. Fifty-one effect sizes averaged moderately strong overall benefits of PIIs (g = 0.553), with studies having lower risk of research bias yielding lower estimates (g = 0.47). Parent and observer ratings yielded similar averaged estimates for positive behavior/social skills (g = 0.603), language/communication (g = 0.545), maladaptive behavior (g = 0.519), and to a lesser extent, adaptive behavior/life skills (g = 0.239). No other study, intervention, or participant characteristic moderated outcomes. PIIs with children with ASD tend to be effective across a variety of circumstances.

Why it is so challenging to perform economic evaluations of interventions in autism and what to do about it

Economic evaluation is used to determine the optimal provision of services and programs under budget constraints and to inform public and private payer funding decisions. To maximize value-for-money in the design and delivery of programs and services for persons with autism spectrum disorder (ASD), it's essential to generate high-quality economic evidence to inform budget allocation. There is a paucity however, of economic evaluations of interventions for ASD. This is due in part to challenges in conducting economic evaluations in this population and the lack of guidance on suitable approaches. These challenges are related to the inherent heterogeneity of the autistic population; establishing short- and long-term effectiveness; measurement of costs and the availability of valid instruments for collecting economic data; the appropriateness of outcomes for use in economic evaluation; and achieving statistical power. This commentary addresses a lack of awareness and needed guidance on these issues by discussing the challenges and providing recommendations for how economic evaluations in ASD could be improved to generate high-quality evidence for program funding decision-making.

Autism Caregiver Coaching in Africa (ACACIA): Protocol for a type 1-hybrid effectiveness-implementation trial

Background

While early autism intervention can significantly improve outcomes, gaps in implementation exist globally. These gaps are clearest in Africa, where forty percent of the world's children will live by 2050. Task-sharing early intervention to non-specialists is a key implementation strategy, given the lack of specialists in Africa. Naturalistic Developmental Behavioral Interventions (NDBI) are a class of early autism intervention that can be delivered by caregivers. As a foundational step to address the early autism intervention gap, we adapted a non-specialist delivered caregiver coaching NDBI for the South African context, and pre-piloted this cascaded task-sharing approach in an existing system of care.

Objectives

First, we will test the effectiveness of the caregiver coaching NDBI compared to usual care. Second, we will describe coaching implementation factors within the Western Cape Department of Education in South Africa.

Methods

This is a type 1 effectiveness-implementation hybrid design; assessor-blinded, group randomized controlled trial. Participants include 150 autistic children (18-72 months) and their caregivers who live in Cape Town, South Africa, and those involved in intervention implementation. Early Childhood Development practitioners, employed by the Department of Education, will deliver 12, one hour, coaching sessions to the intervention group. The control group will receive usual care. Distal co-primary outcomes include the Communication Domain Standard Score (Vineland Adaptive Behavior Scales, Third Edition) and the Language and Communication Developmental Quotient (Griffiths Scales of Child Development, Third Edition). Proximal secondary outcome include caregiver strategies measured by the sum of five items from the Joint Engagement Rating Inventory. We will describe key implementation determinants.

Results

Participant enrolment started in April 2023. Estimated primary completion date is March 2027.

Conclusion

The ACACIA trial will determine whether a cascaded task-sharing intervention delivered in an educational setting leads to meaningful improvements in communication abilities of autistic children, and identify implementation barriers and facilitators.

Diagnostic Accuracy of Primary Care Clinicians Across a Statewide System of Autism Evaluation

OBJECTIVES

To evaluate the diagnostic accuracy of the Early Autism Evaluation (EAE) Hub system, a statewide network that provides specialized training and collaborative support to community primary care providers in the diagnosis of young children at risk for autism spectrum disorder (ASD).

METHODS

EAE Hub clinicians referred children, aged 14 to 48 months, to this prospective diagnostic study for blinded follow-up expert evaluation including assessment of developmental level, adaptive behavior, and ASD symptom severity. The primary outcome was agreement on categorical ASD diagnosis between EAE Hub clinician (index diagnosis) and ASD expert (reference standard).

RESULTS

Among 126 children (mean age: 2.6 years; 77% male; 14% Latinx; 66% non-Latinx white), 82% (n = 103) had consistent ASD outcomes between the index and reference evaluation. Sensitivity was 81.5%, specificity was 82.4%, positive predictive value was 92.6%, and negative predictive value was 62.2%. There was no difference in accuracy by EAE Hub clinician or site. Across measures of development, there were significant differences between true positive and false negative (FN) cases (all Ps < .001; Cohen's d = 1.1-1.4), with true positive cases evidencing greater impairment.

CONCLUSIONS

Community-based primary care clinicians who receive specialty training can make accurate ASD diagnoses in most cases. Diagnostic disagreements were predominately FN cases in which EAE Hub clinicians had difficulty differentiating ASD and global developmental delay. FN cases were associated with a differential diagnostic and phenotypic profile. This research has significant implications for the development of future population health solutions that address ASD diagnostic delays.

Randomized, controlled trial of a mixed early start Denver model for toddlers and preschoolers with autism

The early start Denver model (ESDM) has been extensively studied as a promising early intervention approach for young children with autism spectrum disorder (ASD). Various methodological drawbacks from earlier ESDM investigations must be rectified to expand the application scopes. For this purpose, the present study recruited a very large sample of 249 autistic children (aged 24-47 months), and used a randomized controlled design to compare outcomes from a mixed ESDM (M-ESDM) intervention with a mixed discrete trial teaching (M-DTT) intervention which remains one of the most commonly-used programming for early intervention. Over the course of a 12-week period, both groups (i.e., M-ESDM and M-DTT groups) received 25 h of intensive intervention per week using individual, group, and parent coaching techniques. Findings showed that: (i) the M-ESDM significantly outperformed the M-DTT in enhancing children's developmental abilities in gross motor and personal-social skills for toddlers and preschoolers, as well as in language for preschoolers with mild/moderate ASD and toddlers; and (ii) the M-ESDM dramatically reduced the severity of autistic symptoms in toddlers with severe ASD only, when compared to the M-DTT. However, the M-ESDM did not outperform the M-DTT in terms of improving children's developmental abilities in adaptability and fine motor for toddlers and preschoolers, as well as in language for preschoolers with severe ASD. In addition, when compared to the M-DTT, the M-ESDM did not show an advantage in reducing the severity of autistic symptoms in toddlers with mild/moderate ASD and preschoolers. Clinical Trial Registration: Chinese Clinical Trial Registry. Registration number ChiCTR200039492.

Identifying neurodevelopmental disabilities from nationalised preschool health check

OBJECTIVE

Models of psychometric screening to identify individuals with neurodevelopmental disabilities (NDDs) have had limited success. In Aotearoa/New Zealand, routine developmental surveillance of preschool children is undertaken using the Before School Check (B4SC), which includes psychometric and physical health screening instruments. This study aimed to determine whether combining multiple screening measures could improve the prediction of NDDs.

METHODS

Linked administrative health data were used to identify NDDs, including attention deficit hyperactivity disorder, autism spectrum disorder and intellectual disability, within a multi-year national cohort of children who undertook the B4SC. Cox proportional hazards models, with different combinations of potential predictors, were used to predict onset of a NDD. Harrell's c-statistic for composite models were compared with a model representing recommended cutoff psychometric scores for referral in New Zealand.

RESULTS

Data were examined for 287,754 children, and NDDs were identified in 10,953 (3.8%). The best-performing composite model combining the Strengths and Difficulties Questionnaire, the Parental Evaluation of Developmental Status, vision screening and biological sex had 'excellent' predictive power (C-statistic: 0.83) compared with existing referral pathways which had 'poor' predictive power (C-statistic: 0.68). In addition, the composite model was able to improve the sensitivity of NDD diagnosis detection by 13% without any reduction in specificity.

CONCLUSIONS

Combination of B4SC screening measures using composite modelling could lead to significantly improved identification of preschool children with NDDs when compared with surveillance that rely on individual psychometric test results alone. This may optimise access to academic, personal and family support for children with NDDs.

Efficacy and moderating factors of the Early Start Denver Model in Chinese toddlers with autism spectrum disorder: a longitudinal study

BACKGROUND

Several studies have shown the effectiveness of the Early Start Denver Model (ESDM), but few studies have explored the long-term efficacy of ESDM. This study aimed to explore the efficacy and moderating factors of ESDM in Chinese toddlers with autism spectrum disorder (ASD) in a longitudinal way.

METHODS

A total of 60 toddlers with ASD were recruited and randomly divided into two groups: ESDM group all received 24 weeks intervention; Control group were waiting for intervention. Baseline assessment (T0) was conducted before intervention, including Gesell Developmental Scale (GDS) and Psycho-educational Profile-3rd Edition (PEP-3). All toddlers with ASD were examined in the first assessment (T1) at 6 months and in the second assessment (T2) at 12 months.

RESULTS

In T1 assessment, the increments in speech and personal communication development quotient in GDS were significantly larger in the ESDM group than in the control group (P = 0.010, 0.047). In T2 assessment, the ESDM group had higher elevation in cognitive verbal/preverbal (CVP), social reciprocity and characteristic verbal behaviors assessed by PEP-3 (P = 0.021, 0.046, 0.014). In addition, the severity of stereotyped behavior was negatively associated with improvement in CVP. Family income was positively associated with improvement in speech and CVP (all P < 0.05).

CONCLUSIONS

ESDM can effectively improve speech and communication in toddlers with ASD after 24-week intervention. More importantly, ESDM can promote cognition and social interaction and can reduce stereotyped verbal behavior in toddlers with ASD in longitudinal observation. The severity of stereotyped behavior and family ecological factors may be considered as affecting the efficacy of ESDM.

Estimated Therapy Costs and Downstream Cost Consequences of iBASIS-Video Interaction to Promote Positive Parenting Intervention vs Usual Care Among Children Displaying Early Behavioral Signs of Autism in Australia

Importance

The growing global prevalence of autism spectrum disorder (ASD) is associated with increasing costs for support services. Ascertaining the effects of a successful preemptive intervention for infants showing early behavioral signs of autism on human services budgets is highly policy relevant.

Objective

To estimate the net cost impact of the iBASIS-Video Interaction to Promote Positive Parenting (iBASIS-VIPP) intervention on the Australian government.

Design, Setting, and Participants

Infants (aged 12 months) showing early behavioral indicators of autism were recruited through community settings into the multicenter Australian iBASIS-VIPP randomized clinical trial (RCT), a 5- to 6-month preemptive parent-mediated intervention, between June 9, 2016, and March 30, 2018, and were followed up for 18 months to age 3 years. This economic evaluation, including cost analysis (intervention and cost consequences) and cost-effectiveness analyses of iBASIS-VIPP compared with usual care (treatment as usual [TAU]), modeled outcomes observed at age 3 through to 12 years (13th birthday) and was conducted from April 1, 2021, to January 30, 2023. Data analysis was conducted from July 1, 2021, to January 29, 2023.

Exposures

iBASIS-VIPP intervention.

Main Outcomes and Measures

To project the diagnostic trajectory and associated disability support costs drawing on the Australian National Disability Insurance Scheme (NDIS), the main outcome was the differential treatment cost of iBASIS-VIPP plus TAU vs TAU and disability-related government costs modeled to age 12 years, using a clinical diagnosis of ASD and developmental delay (with autism traits) at 3 years. Costs were calculated in Australian dollars and converted to US dollars. Economic performance was measured through the following: (1) differential net present value (NPV) cost (iBASIS-VIPP less TAU), (2) investment return (dollars saved for each dollar invested, taking a third-party payer perspective), (3) break-even age when treatment cost was offset by downstream cost savings, and (4) cost-effectiveness in terms of the differential treatment cost per differential ASD diagnosis at age 3 years. Alternate values of key parameters were modeled in 1-way and probabilistic sensitivity analysis, the latter identifying the likelihood of an NPV cost savings.

Results

Of the 103 infants enrolled in the iBASIS-VIPP RCT, 70 (68.0%) were boys. Follow-up data at age 3 years were available for 89 children who received TAU (44 [49.4%]) or iBASIS-VIPP (45 [50.6%]) and were included in this analysis. The estimated mean differential treatment cost was A $5131 (US $3607) per child  for iBASIS-VIPP less TAU. The best estimate of NPV cost savings was A $10 695 (US $7519) per child (discounted at 3% per annum). For each dollar invested in treatment, a savings of A $3.08 (US $3.08) was estimated; the break-even cost occurred at age 5.3 years (approximately 4 years after intervention delivery). The mean differential treatment cost per lower incident case of ASD was A $37 181 (US $26 138). We estimated that there was an 88.9% chance that iBASIS-VIPP would deliver a cost savings for the NDIS, the dominant third-party payer.

Conclusions and Relevance

The results of this study suggest that iBASIS-VIPP represents a likely good-value societal investment for supporting neurodivergent children. The estimated net cost savings were considered conservative, as they covered only third-party payer costs incurred by the NDIS and outcomes were modeled to just age 12 years. These findings further suggest that preemptive interventions may be a feasible, effective, and efficient new clinical pathway for ASD, reducing disability and the costs of support services. Long-term follow-up of children receiving preemptive intervention is needed to confirm the modeled results.

Overcoming tensions between family-centered care and fidelity within Early Intervention implementation research

LAY ABSTRACT

Early Intervention systems provide therapeutic services to families of young children birth to 3 years with developmental delays and are considered a natural access point to services for young children and their families. Research studies in the autism field have been interested in training providers to deliver evidence-based practices in Early Intervention systems to increase access to services for young children with an increased likelihood of being autistic. However, research has often overlooked that Early Intervention systems prioritize family-centered care, an approach to working with families that honors and respects their values and choices and that provides supports to strengthen family functioning. This commentary points out that family-centered care deserves greater attention in research being done in Early Intervention systems. We describe how family-centered care may shape how interventions are delivered, and discuss directions for future research to evaluate the impact of family-centered care alongside intervention delivery.

Increased delay from initial concern to diagnosis of autism spectrum disorder and associated health care resource utilization and cost among children aged younger than 6 years in the United States

BACKGROUND: Prolonged delays between first caregiver concern and autism spectrum disorder (ASD) diagnosis have been reported, but associations between length of time to diagnosis (TTD) and health care resource utilization (HCRU) and costs have not been studied in a large sample of children with ASD. OBJECTIVE: To address these informational gaps in the ASD diagnostic pathway. METHODS: This retrospective, observational, single cohort analysis of Optum's administrative claims data from January 1, 2011, to December 31, 2020, included commercially insured children who had 2 or more claims for an ASD diagnosis (earliest diagnosis designated as the index date), were between the ages of older than 1.5 years and 6 years or younger at index date, and were continuously enrolled for up to 48 months before and for 12 months after the index date. Two cohorts (between the ages of older than 1.5 years and 3 years or younger and between the ages of older than 3 years and 6 years or younger at ASD diagnosis) were divided into shorter (less than median) and longer (greater than or equal to median) TTD around each cohort median TTD calculated from the first documented ASD-related concern to the earliest ASD diagnosis, because TTD may vary by age at diagnosis. This exploratory analysis compared all-cause and ASD-related HCRU and costs during a 12-month period preceding ASD diagnosis among children with shorter vs longer TTD. RESULTS: 8,954 children met selection criteria: 4,205 aged 3 years or younger and 4,749 aged older than 3 years at diagnosis, with median TTD of 9.5 and 22.1 months, respectively. In the year preceding ASD diagnosis, children with longer TTD in both age cohorts experienced a greater number of all-cause and ASD-related health care visits compared with those with shorter TTD (mean and median number of office or home visits were approximately 1.5- and 2-fold greater in longer vs shorter TTD groups; P < 0.0001). The mean all-cause medical cost per child in the year preceding ASD diagnosis was approximately 2-fold higher for those with longer vs shorter TTD ($5,268 vs $2,525 in the younger and $5,570 vs $2,265 in the older cohort; P < 0.0001 for both). Mean ASD-related costs were also higher across age cohorts for those with longer vs shorter TTD ($2,355 vs $859 in the younger and $2,351 vs $1,144 in the older cohort; P < 0.0001 for both). CONCLUSIONS: In the year prior to diagnosis, children with longer TTD experienced more frequent health care visits and greater cost burden in their diagnostic journey compared with children with shorter TTD. Novel diagnostic approaches that could accelerate TTD may reduce costs and HCRU for commercially insured children. DISCLOSURES: This study was funded by Cognoa, Inc. Optum received funding from Cognoa to conduct this study. Dr Salomon is an employee and holds stock options of Cognoa, Inc. Dr Campbell was an employee of Cognoa, Inc., at the time this study was conducted. Dr Duhig was an employee of Cognoa, Inc., at the time the study was conducted and holds stock options. Dr Vu, Ms Kruse, Mr Gaur, and Ms Gupta are employees and/or stockholders of Optum. Dr Tibrewal was an employee of Optum at the time the research for this study was conducted. Dr Taraman is an employee and holds stock options of Cognoa, Inc., receives consulting fees from Cognito Therapeutics, volunteers as a board member of the American Academy of Pediatrics California and Orange County Chapter, is a paid advisor for MI10 LLC, and owns stock options of NTX, Inc., and HandzIn.

Addressing current barriers to autism diagnoses through a tiered diagnostic approach involving pediatric primary care providers

Formal autism diagnosis from a specialist trained in autism assessment is customary prior to a child accessing early, intensive autism-specific services. However, long wait lists for diagnostic evaluations and limited specialty workforce have created substantial delays. Additionally, lengthy multidisciplinary evaluations are costly to insurers, inconvenient to families, and disproportionally impact under-resourced families. Diagnostic delays can impede access to intervention services. These barriers, combined with evidence regarding the importance of receiving early, autism-specific treatment, demand new approaches enabling access to autism specific services before comprehensive evaluation. Pediatric primary care providers (PCPs) are often the only health care professionals with whom a family interacts during early childhood and can play a crucial role in helping children with autism symptoms access services. Many strategies for autism diagnosis in primary care are being developed and tested; however, they have yet to be broadly adopted by PCPs, primarily due to critical implementation barriers in primary care settings. There is also not enough evidence on the accuracy of PCPs' diagnostic impressions without extensive specialty support, resulting in PCP hesitancy in diagnosing ASD, as well as family and service provider hesitancy in accepting a PCP autism diagnosis. In this commentary, we explore the acute need for shortening waitlists for autism evaluations through a tiered diagnostic approach, in which PCPs can rule in or rule out autism in children, for whom diagnosis is clear, and refer more complex cases for specialist evaluations, and explore implementation challenges to this approach.

Addressing the Need for Training More School Psychologists to Serve Toddlers and Preschoolers with Autism Spectrum Disorders

The prevalence of autism spectrum disorder (ASD) has risen significantly in the past two decades. Unfortunately, there is a shortage of mental health providers who have specialized training in delivering evidenced-based services to this population. Early intensive behavioral intervention (EIBI) is an evidenced-based treatment recommended for toddlers with ASD, and school psychologists are uniquely positioned to help children with ASD receive it. However, many school psychologists do not receive adequate training in this subspecialty. This paper makes recommendations to school psychology training programs about how to add or improve training in this subspecialty based on the results of an Office of Special Education Programs grant-funded ASD training program which involved collaboration between a NASP-approved and APA-accredited school psychology training program and a community-based early intensive behavioral intervention (EIBI) clinic. The grant supported development of an interdisciplinary didactic and clinical training program to increase the ASD knowledge, skills, and competencies of school psychology graduate students, with the broader goals of developing a replicable training model and increasing the workforce of trained providers for this underserved population. Fifteen graduate students completed the training program. Outcomes related to trainee knowledge, skills, and competencies, trainee satisfaction, and lessons learned over time analyzed within a logic model that guided the project's development and execution can be informative for other school psychology programs undertaking training in this subspecialty.

Early intervention for very young children with or at high likelihood for autism spectrum disorder: An overview of reviews

AIM

To identify which interventions are supported by evidence and the quality of that evidence in very young children with or at high likelihood for autism spectrum disorder (ASD) to improve child outcomes.

METHOD

We conducted an overview of reviews to synthesize early intervention literature for very young children with or at high likelihood for ASD. Cochrane guidance on how to perform overviews of reviews was followed. Comprehensive searches of databases were conducted for systematic reviews and meta-analyses between January 2009 and December 2020. Review data were extracted and summarized and methodological quality was assessed. Primary randomized controlled trial evidence was summarized and risk of bias assessed. This overview of reviews was not registered.

RESULTS

From 762 records, 78 full texts were reviewed and seven systematic reviews and meta-analyses with 63 unique studies were identified. Several interventional approaches (naturalistic developmental behavioral intervention, and developmental and behavioral interventions) improved child developmental outcomes. Heterogeneity in design, intervention and control group, dose, delivery agent, and measurement approach was noted. Inconsistent methodological quality and potential biases were identified.

INTERPRETATION

While many early interventional approaches have an impact on child outcomes, study heterogeneity and quality had an impact on our ability to draw firm conclusions regarding which treatments are most effective. Advances in trial methodology and design, and increasing attention to mitigating measurement bias, will advance the quality of the ASD early intervention evidence base.

WHAT THIS PAPER ADDS

Naturalistic developmental behavioral interventions, as well as developmental and behavioral interventions, improve child outcomes in autism spectrum disorder (ASD). If only randomized controlled trials are considered, guidelines for early intensive behavioral intervention in younger children should be revisited. The greatest intervention impacts were on proximal, intervention-specific outcomes. Inadequacies in the quality of the early ASD intervention evidence base were observed.

Autism Tsunami: the Impact of Rising Prevalence on the Societal Cost of Autism in the United States

The cost of ASD in the U.S. is estimated using a forecast model that for the first time accounts for the true historical increase in ASD. Model inputs include ASD prevalence, census population projections, six cost categories, ten age brackets, inflation projections, and three future prevalence scenarios. Future ASD costs increase dramatically: total base-case costs of $223 (175-271) billion/year are estimated in 2020; $589 billion/year in 2030, $1.36 trillion/year in 2040, and $5.54 (4.29-6.78) trillion/year by 2060, with substantial potential savings through ASD prevention. Rising prevalence, the shift from child to adult-dominated costs, the transfer of costs from parents onto government, and the soaring total costs raise pressing policy questions and demand an urgent focus on prevention strategies.

Telehealth Evaluation of Pediatric Neurodevelopmental Disabilities During the COVID-19 Pandemic: Clinician and Caregiver Perspectives

OBJECTIVE

The objective of this study was to present clinician and caregiver perspectives regarding telehealth neurodevelopmental evaluation delivered at the onset of the coronavirus disease 2019 (COVID-19) pandemic. Specifically, we sought to describe telehealth neurodevelopmental evaluations, examine associations between child characteristics and diagnostic factors, determine the impact of technology and family barriers, and report on clinician and caregiver satisfaction with telehealth evaluation.

METHODS

In response to the COVID-19 pandemic, in-person clinical services at a large children's hospital neurodevelopmental clinic were transitioned to telehealth. Data are presented for 254 remote evaluations of children (18-212 months; referral concern: 51% autism spectrum disorder [ASD], 24% developmental delay/intellectual disability, 25% other neurodevelopmental concern) conducted from May to July 2020. Data were gathered from electronic health records as well as clinician and caregiver surveys.

RESULTS

A clinical diagnosis was provided in 72% of telehealth evaluations. Clinicians rated diagnostic certainty as "completely" or "somewhat" certain in 74% of evaluations. Certainty ratings were higher for evaluations in which a diagnosis of ASD was provided. Although technology and family challenges were reported, clinicians rarely identified these as disruptive to the evaluation process. Clinicians reported satisfaction with various aspects of delivering telehealth. Caregivers endorsed high satisfaction with receipt of telehealth and reduced travel burden.

CONCLUSION

The COVID-19 pandemic has rapidly transformed service delivery for individuals with neurodevelopmental disabilities and provided an unprecedented opportunity to evaluate the deployment of telehealth evaluation to meet the need for ongoing diagnostic care. Our findings suggest that telehealth holds significant promise for neurodevelopmental assessment both within the context of a global pandemic and beyond.

A Machine Learning Approach in Autism Spectrum Disorders: From Sensory Processing to Behavior Problems

Atypical sensory processing described in autism spectrum disorders (ASDs) frequently cascade into behavioral alterations: isolation, aggression, indifference, anxious/depressed states, or attention problems. Predictive machine learning models might refine the statistical explorations of the associations between them by finding out how these dimensions are related. This study investigates whether behavior problems can be predicted using sensory processing abilities. Participants were 72 children and adolescents (21 females) diagnosed with ASD, aged between 6 and 14 years (M = 7.83 years; SD = 2.80 years). Parents of the participants were invited to answer the Sensory Profile 2 (SP2) and the Child Behavior Checklist (CBCL) questionnaires. A collection of 26 supervised machine learning regression models of different families was developed to predict the CBCL outcomes using the SP2 scores. The most reliable predictions were for the following outcomes: total problems (using the items in the SP2 touch scale as inputs), anxiety/depression (using avoiding quadrant), social problems (registration), and externalizing scales, revealing interesting relations between CBCL outcomes and SP2 scales. The prediction reliability on the remaining outcomes was “moderate to good” except somatic complaints and rule-breaking, where it was “bad to moderate.” Linear and ridge regression achieved the best prediction for a single outcome and globally, respectively, and gradient boosting machine achieved the best prediction in three outcomes. Results highlight the utility of several machine learning models in studying the predictive value of sensory processing impairments (with an early onset) on specific behavior alterations, providing evidences of relationship between sensory processing impairments and behavior problems in ASD.

Developmental Behavioral Pediatrician Perspectives on Decision-Making in Early Treatment Planning for Children with Autism Spectrum Disorder

OBJECTIVE

Providers of children with autism spectrum disorder (hereafter "autism") report higher levels of shared decision-making during initial diagnostic and treatment planning visits than observed. The goal of this study was to qualitatively explore this discrepancy by investigating provider perceptions of the parent-provider decision-making process in early treatment planning and the role for parents in this process.

METHODS

We conducted semistructured qualitative interviews with developmental behavioral pediatricians (DBPs; n = 15) to investigate how they approach early treatment planning with parents. We analyzed participant characteristics using descriptive statistics. Interviews were audio-recorded, transcribed, and independently coded by 2 researchers until consensus was reached. Analyses were conducted using a modified grounded theory framework.

RESULTS

DBPs reported that their primary role during early treatment planning was to provide diagnostic clarification and that parents' primary role was to learn as much as they can about autism. Most DBPs wanted treatment planning to be collaborative, and perceived that parents had the same preference but might not have the knowledge or skills to effectively participate. DBPs identified additional barriers that influence the extent to which they engage parents in the collaborative decision-making and provided recommendations for enhancing the process.

CONCLUSION

DBPs are proponents of collaborative treatment planning between parents and providers; however, there are many obstacles that prevent this. Strategies such as decision tools or aids and larger systemic reforms are necessary to support DBPs and parents in this process.

Who’s waiting for a school? Rates, socio-demographics, disability and referral profile of children with autism spectrum disorder awaiting school placement in the Western Cape Province of South Africa

In this study, we examined the demographic, disability, referral and service needs profile of children with autism spectrum disorder waiting for school placement in the Western Cape Province of South Africa and combined our findings with those of a previous study on children with autism spectrum disorder attending schools in the province over the same period of time. In June 2016, there were 744 children with autism spectrum disorder or suspected autism spectrum disorder waiting for an appropriate school placement, 478 children were pre-school age and 266 children were school-going age. Fifty-three percent (53%) of pre-school age children and 38% of school-going age children were reported to be at home and receiving no educational or other intervention while they waited for a school. More than half the children on the waiting list had been waiting for services for more than a year. The combined data on children with autism spectrum disorder in school and waiting for schools showed a total of 1684 known children with autism spectrum disorder in the Western Cape in June 2016, representing less than 0.1% of the childhood population in the province. The results highlight the need for education systems strengthening to accommodate all children with autism spectrum disorder in appropriate educational settings from as early as possible. We propose multi-stakeholder engagement to develop contextually appropriate policies, best practice guidelines and actions for the education of children with autism spectrum disorder in South Africa.

Lay abstract

In South Africa, there are limited educational opportunities for children with autism spectrum disorder and many children with autism spectrum disorder have to wait for school placement. This study examined the education waiting list for children with autism spectrum disorder in the Western Cape Province of South Africa and reported on the demographic, disability, referral and service provision characteristics of these children. In June 2016, there were 744 children with definite autism spectrum disorder or possible autism spectrum disorder between the ages of 1 and 17 years waiting for school placement. There were children of compulsory school-going age who were reported to be at home and not receiving any intervention while they waited. More than half the children on the waiting list had been waiting for more than a year. We then combined the findings of this study with the findings of a previous study on children with autism spectrum disorder already attending schools in the province over the same period of time. We found a total of 1684 children known to have autism spectrum disorder – this was less than 0.1% of all young people in the province at the time. Between 2012 and 2016, there was a 276% increase in the number of children with autism spectrum disorder waiting for schools in the Western Cape. The results show that education systems in the Western Cape need to be strengthened to accommodate all children with autism spectrum disorder in appropriate education settings from as early as possible. We recommend engaging with different stakeholders to develop policies, best practice guidelines and actions for autism spectrum disorder education in South Africa.

Proactive versus Reactive: Strategies in the Implementation of School-based Services for Students with ASD

Autism spectrum disorder (ASD) is increasingly prevalent, intervention costs are high, and long-term outcomes are poor. Proactive implementation of evidence-based practices (EBPs; Steinbrenner et al., Evidence-Based Practices for Children, Youth, and Young Adults with Autism, 2020) through an assessment or planning process can lead to more effective services (Rubin et al., Admin Policy Mental Health Mental Health Serv Res 43(6), 1023-1028, 2016). The objective of this study is (a) to identify factors associated with the use of proactive versus reactive strategies for school-based services for students with ASD and (b) to examine school personnel perceptions of the use of proactive versus reactive strategies. Data were from a larger project in which 6 semi-structured focus groups were conducted to understand school personnel perceptions of how school districts implement new programs for ASD. Transcripts were coded using an iterative coding and review process. In the present study, primary themes were identified and classified as proactive or reactive. Participants reported both proactive and reactive allocation of district resources for intervention implementation. Reactive implementation was associated with litigation or due process, escalated student behavior, and non-public school placement, whereas proactive implementation was associated with ASD-specific programming, grants, personnel experience with EBPs, and prospective needs assessment. Participants perceived the reactive strategies as disadvantageous, and yet these strategies were sometimes still employed. Understanding the role of proactive and reactive strategies and the factors that influence their use could enable more effective planning for EBP use to improve both cost savings and student outcomes. This study is an important first step to explore resource allocation for school-based services for students with ASD.

Distinct Patterns of Cognitive Outcome in Young Children With Autism Spectrum Disorder Receiving the Early Start Denver Model

Evidence-based, early intervention significantly improves developmental outcome in young children with autism. Nonetheless, there is high interindividual heterogeneity in developmental trajectories during the therapy. It is established that starting intervention as early as possible results in better developmental outcomes. But except for younger age at start, there is no clear consensus about behavioral characteristics that could provide a reliable individual prediction of a child's developmental outcome after receiving an early intervention. In this study, we analyze developmental trajectories of preschoolers with autism who received 2 years of intervention using the Early Start Denver Model (ESDM) approach in Geneva, Switzerland in an individual setting (n = 55, aged 28.7 ± 5.1 months with a range of 15-42). Our aim was to identify early predictors of response to intervention. We applied a cluster analysis to distinguish between 3 groups based on their cognitive level at intake, and rates of cognitive change over the course of intervention. The first group of children only had a mild cognitive delay at intake and nearly no cognitive delay by the end of intervention (Higher Cognitive at baseline: HC). The children in the two other groups all presented with severe cognitive delay at baseline. However, they had two very different patterns of response to intervention. The majority significantly improved developmental scores over the course of intervention (Optimal Responders: OptR) whereas a minority of children showed only modest improvement (Minimal Responders: MinR). Further analyses showed that children who ended up having an optimal 2-year intervention outcome (OptR) were characterized by higher adaptive functioning at baseline combined with rapid developmental improvement during the first 6 months of intervention. Inversely, less significant progress by the sixth month of intervention was associated with a less optimal response to treatment (MinR).

Quickstart for toddlers with autism spectrum disorder: A preliminary report of an adapted community-based early intervention program

Background and Aims

Early intervention (EI) for young children with autism spectrum disorder (ASD) must be resource-efficient while remaining effective; thus, clinicians are challenged to create and implement useful methods. Clinical evidence from community-based interventions that include reliable diagnoses, individual EI programs, along with comprehensive descriptions of participants, procedures, and participant outcomes can inform practice, translational research, and local policy. Parent-mediated EI for toddlers with ASD can promote positive developmental outcomes and lifelong well-being, but evidence of successful community uptake of research-based EIs is somewhat limited. The community-based, parent-mediated, evidence-informed QuickStart EI program aims to encourage toddlers' early social communication, social interactions, and relationship-building, in a community clinic setting.We aim to (1) describe our adaptations to the evidence-based Parent-Delivered Early Start Denver Model and (2) present promising findings for toddlers with or at risk for ASD and their families who received QuickStart. We also intend to motivate a similar study of EI in real-world situations to advance evidence-based practice and create relevant dialogue and questions for research.

Methods

Complete data were identified and analyzed for up to 89 toddlers diagnosed with, or at risk of, ASD. Pre- and post-intervention parent- or self-report data were analyzed using descriptive statistics and paired-sample t-tests, as appropriate. Pre-intervention measures included demographic information (n = 89) and the Early Screening of Autism and Communication (ESAC; n = 89). Measures taken pre- and post-intervention included the Adaptive Behavior Assessment System-II (n = 60), MacArthur-Bates Communication Development Inventories (n = 58), and the parental sense of competence scale (n = 62). The Measure of Processes of Care (n = 60) was taken post-intervention. On enrollment, parents signed standard clinical agreements that included statements allowing their anonymous data to be analyzed for research.

Results

Using standardized parent/self-report measures, toddler gains were noted for social interaction, language, communication skills, and ASD symptoms, but not for parents' feelings of competence. Parents identified QuickStart procedures as family centered (Measure of Processes of Care).

Conclusions

The QuickStart EI program, provided to toddlers and their families over 20 weeks in a community clinic, resulted in promising positive behavior and communication changes, as indicated on the parent-response measures, for a moderately large sample of toddlers.

Implications

This study adds to the literature by describing a new EI program with clear procedures by which clinicians can create, provide, and evaluate a readily accessible, community-based EI for toddlers with or at risk of ASD. Methodological limitations inherent to our study design that precluded a control group and necessitated a reliance on available parent-report data are carefully critiqued and discussed.

The cost-effectiveness of treatments for attention deficit-hyperactivity disorder and autism spectrum disorder in children and adolescents: a systematic review

Economic evaluations can help decision makers identify what services for children with neurodevelopmental disorders provide best value-for-money. The aim of this paper is to review the best available economic evidence to support decision making for attention deficit-hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in children and adolescents. We conducted a systematic review of economic evaluations of ADHD and ASD interventions including studies published 2010-2020, identified through Econlit, Medline, PsychINFO, and ERIC databases. Only full economic evaluations comparing two or more options, considering both costs and consequences were included. The quality of the studies was assessed using the Drummond checklist. We identified ten studies of moderate-to-good quality on the cost-effectiveness of treatments for ADHD and two studies of good quality of interventions for ASD. The majority of ADHD studies evaluated pharmacotherapy (n = 8), and two investigated the economic value of psychosocial/behavioral interventions. Both economic evaluations for ASD investigated early and communication interventions. Included studies support the cost-effectiveness of behavioral parenting interventions for younger children with ADHD. Among pharmacotherapies for ADHD, different combinations of stimulant/non-stimulant medications for children were cost-effective at willingness-to-pay thresholds reported in the original papers. Early intervention for children with suspected ASD was cost-effective, but communication-focused therapy for preschool children with ASD was not. Prioritizing more studies in this area would allow decision makers to promote cost-effective and clinically effective interventions for this target group.

A Mobile Game Platform for Improving Social Communication in Children with Autism: A Feasibility Study

Background  Many children with autism cannot receive timely in-person diagnosis and therapy, especially in situations where access is limited by geography, socioeconomics, or global health concerns such as the current COVD-19 pandemic. Mobile solutions that work outside of traditional clinical environments can safeguard against gaps in access to quality care.

Objective  The aim of the study is to examine the engagement level and therapeutic feasibility of a mobile game platform for children with autism.

Methods  We designed a mobile application, GuessWhat , which, in its current form, delivers game-based therapy to children aged 3 to 12 in home settings through a smartphone. The phone, held by a caregiver on their forehead, displays one of a range of appropriate and therapeutically relevant prompts (e.g., a surprised face) that the child must recognize and mimic sufficiently to allow the caregiver to guess what is being imitated and proceed to the next prompt. Each game runs for 90 seconds to create a robust social exchange between the child and the caregiver.

Results  We examined the therapeutic feasibility of GuessWhat in 72 children (75% male, average age 8 years 2 months) with autism who were asked to play the game for three 90-second sessions per day, 3 days per week, for a total of 4 weeks. The group showed significant improvements in Social Responsiveness Score-2 (SRS-2) total (3.97, p <0.001) and Vineland Adaptive Behavior Scales-II (VABS-II) socialization standard (5.27, p  = 0.002) scores.

Conclusion  The results support that the GuessWhat mobile game is a viable approach for efficacious treatment of autism and further support the possibility that the game can be used in natural settings to increase access to treatment when barriers to care exist.

Evaluation of the Feasibility and Perceived Value of Integrating Learn the Signs. Act Early. Developmental Monitoring Resources in Early Head Start

Many children with developmental disabilities are not identified before age 3 years old preventing them from being able to fully benefit from early intervention services. Early childhood educators, particularly those in Early Head Start (EHS) programs, are important partners in the early identification of children with developmental delays. Learn the Signs. Act Early. (LTSAE) is a program of the U.S. Centers for Disease Control and Prevention that provides free developmental monitoring resources to increase the early identification of children with developmental delays and disabilities. This paper presents findings from the first evaluation of the use of LTSAE resources in EHS, which was conducted across four states and 11 EHS programs from fall 2018 through spring 2019. Surveys (n=448) and interviews (n=39) with EHS management, staff, and parents indicated that LTSAE resources were valued and accepted, and their use in EHS considered feasible. Importantly, families and staff reported the LTSAE materials provided shared language to help them more effectively discuss development. These findings inform EHS and other early education programs that wish to enhance developmental monitoring, screening, and referral.

Associations Among Referral Concerns, Screening Results, and Diagnostic Outcomes of Young Children Assessed in a Statewide Early Autism Evaluation Network

OBJECTIVES

To examine associations between referral concerns, screening results, and diagnostic outcomes for young children evaluated across a statewide primary care network for early screening and diagnosis of autism spectrum disorder (ASD).

STUDY DESIGN

The Early Autism Evaluation Hub system was developed to increase developmental screening and improve access to timely ASD evaluations in local communities. In 2019, 858 children (ages 18-48 months; 40% diagnosed with ASD) received ASD evaluations across 12 Early Autism Evaluation Hubs. Data on primary care provider (PCP)- and caregiver-reported referral concerns, Modified Checklist for Autism in Toddlers, Revised with Follow-Up (MCHAT-R/F) and Ages and Stages Questionnaire, Third Edition (ASQ-3), and diagnostic outcome were collected.

RESULTS

Among children evaluated, there was low concordance between PCP and caregiver referral concern. Although a positive MCHAT-R/F screen was associated with PCP but not caregiver-reported ASD referral concern, there was a significant linear relationship between MCHAT-R/F raw scores and both PCP and caregiver ASD referral concern. A different pattern of ASQ-3 delays was found to be associated with PCP-reported as compared with caregiver-reported ASD referral concern. Finally, PCP-reported ASD referral concern, positive MCHAT-R/F, and ASQ-3 Communication and Personal Social delays were associated with a significantly higher likelihood of subsequent ASD diagnosis.

CONCLUSIONS

Understanding how community PCPs use surveillance and screening data, the extent to which PCPs and caregivers have shared understanding and engage in collaborative decision-making about evaluation referral, and how these factors relate to diagnostic outcomes has the potential to impact educational efforts for both PCPs and caregivers of young children, as well as inform the development of more efficacious early identification approaches.

Relationship Between Social Motivation in Children With Autism Spectrum Disorder and Their Parents

Impairment in social motivation (SM) has been suggested as a key mechanism underlying social communication deficits observed in autism spectrum disorder (ASD). However, the factors accounting for variability in SM remain poorly described and understood. The current study aimed to characterize the relationship between parental and proband SM. Data from 2,759 children with ASD (M age = 9.03 years, SD age = 3.57, 375 females) and their parents from the Simons Simplex Collection (SSC) project was included in this study. Parental and proband SM was assessed using previously identified item sets from the Social Responsiveness Scale (SRS). Children who had parents with low SM scores (less impairments) showed significantly lower impairments in SM compared to children who had either one or both parents with elevated SM scores. No parent-of-origin effect was identified. No significant interactions were found involving proband sex or intellectual disability (ID) status (presence/absence of ID) with paternal or maternal SM. This study establishes that low SM in children with ASD may be driven, in part, by lower SM in one or both parents. Future investigations should utilize larger family pedigrees, including simplex and multiplex families, evaluate other measures of SM, and include other related, yet distinct constructs, such as social inhibition and anhedonia. This will help to gain finer-grained insights into the factors and mechanisms accounting for individual differences in sociability among typically developing children as well as those with, or at risk, for developing ASD.

Connecting the Dots: a cluster-randomized clinical trial integrating standardized autism spectrum disorders screening, high-quality treatment, and long-term outcomes

BACKGROUND

Autism spectrum disorder (ASD) affects one in 54 children in the United States of America, and supporting people with ASD across the lifespan presents challenges that impact individuals, families, and communities and can be quite costly. The American Academy of Pediatrics has issued recommendations for routine ASD screening at 18 and 24 months, but some research suggests that few pediatricians perform high-fidelity, standardized screening universally. Furthermore, the United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against universal ASD screening. The objective of this study is to test the hypothesis that children with ASD who have high fidelity; standardized screening will achieve superior outcomes at 5 years of age compared to children receiving usual care ASD detection strategies.

METHODS

This is a cluster-randomized, controlled clinical trial in 3 sites in the USA. Pediatric practices will be randomized to implement universal, standardized, high-fidelity toddler screening or usual care, with randomization stratified by the practice size. The study will enroll 3450 children, approximately half in each group. From this sample, we anticipate 100 children to be diagnosed with ASD. Children in both groups receiving an ASD diagnosis will be administered the Early Start Denver Model, an evidence-based early intervention addressing social, communication, and cognitive functioning. Treatment will last for 1 year, with up to 20 h per week of therapy for children with ASD.

RESULTS

Primary outcomes measured at baseline, following treatment, and at 4 and 5 years of age include ASD symptom severity (Brief Observation of Social Communication Change (BOSCC)) and cognitive functioning (Mullen Scales of Early Learning (MSEL) and Differential Abilities Scale-II (DAS-II)). Secondary outcomes in children include measures of adaptive functioning, ASD symptoms, and kindergarten readiness; secondary analyses will also examine stress and empowerment among parents. Several novel exploratory measures will be included as well. The study will utilize a modified intention-to-treat analysis.

CONCLUSIONS

This trial will evaluate the impact of universal, standardized, high-fidelity screening for ASD among children at 18 months of age, with a goal of providing evidence to support this strategy to detect ASD in toddlers in order to start treatment as young as possible and maximize outcomes.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board at Drexel University (IRB protocol: 1607004653). All findings will be provided by the principal investigator via email; data will be available through the NIMH Data Archive ( https://nda.nih.gov/ ).

TRIAL REGISTRATION

ClinicalTrials.gov NCT03333629 . Registered on November 7, 2017.

Presymptomatic Detection and Intervention for Autism Spectrum Disorder

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.

Estimating Components and Costs of Standard Care for Children with Autism Spectrum Disorder in Europe from a Large International Sample

(1) Background: European guidelines provide recommendations for services and care for people with autism spectrum disorder (ASD), but not all interventions are generally available. Knowledge of service use and costs and wider societal costs in Europe is limited; (2) Method: Using an international sample, we analysed services and costs in 357 children (4-6.99 years) with ASD based on parent reports. Costs were transformed into EU-28 average using purchasing power parity; (3) Results: 122 children (34%) received specialist autism services; 149 (42%) received sensory/motor therapy; 205 (57%) received speech/language therapy; 35 (10%) received play therapy; 55 (15%) received behavioural interventions; 31 (9%) received social skills training; 47 (13%) participated in therapeutic recreational activities; and 59 (17%) received other services. The total number of hours for these services combined over two months was M = 34 (SD = 63; range: 0 -372). Estimated total costs of health-related services were M = 1210 EUR (SD = 2160 EUR); indirect societal costs were M = 1624 EUR (SD = 1317 EUR). Regression analyses suggested that costs rise with age and presence of intellectual disabilities, but not with severity of autism; (4) Conclusions: The high extent of community-based services indicates good accessibility but also considerable variation in the receipt of services. The costs of autism services are considerable. Further research is needed to investigate whether services received match individual needs.

Can the Early Start Denver Model Be Considered ABA Practice?

The Early Start Denver Model (ESDM) is an evidence-based early intervention approach for young children with autism spectrum disorder. Although the ESDM is described by its authors as being rooted in applied behavior analysis (ABA), some states, agencies, and scholars consider the ESDM to qualify as ABA practice, whereas others do not. The purpose of this article is to examine the status of the ESDM in relation to the 7 dimensions established by Baer, Wolf, and Risley ("Some Current Dimensions of Applied Behavior Analysis," Journal of Applied Behavior Analysis, 1(1): 91-97, 1968) to define applied behavior-analytic research and intervention, as well as to discuss implications for the field.

Prevention in Autism Spectrum Disorder: A Lifelong Focused Approach

Autism Spectrum Disorder (ASD) is a complex highly heritable disorder, in which multiple environmental factors interact with the genes to increase its risk and lead to variable clinical presentations and outcomes. Furthermore, the inherent fundamental deficits of ASD in social attention and interaction critically diverge children from the typical pathways of learning, "creating" what we perceive as autism syndrome during the first three years of life. Later in life, training and education, the presence and management of comorbidities, as well as social and vocational support throughout the lifespan, will define the quality of life and the adaptation of an individual with ASD. Given the overall burden of ASD, prevention strategies seem like a cost-effective endeavour that we have to explore. In this paper, we take a life course approach to prevention. We will review the possibilities of the management of risk factors from preconception until the perinatal period, that of early intervention in the first three years of life and that of effective training and support from childhood until adulthood.

A meta-analysis of the effect of the Early Start Denver Model in children with autism spectrum disorder

Objectives: To examine and analyse the intervention effects of the Early Start Denver Model (ESDM) on children with autism spectrum disorder (ASD). Methods: This meta-analysis evaluated the effect sizes in four major domains of measurement (autism symptoms, language, cognition, and social communication). A total of 624 participants with ASD were included in 11 high-quality randomized controlled trial studies. Results: The results indicated that the ESDM intervention resulted in significant improvement with moderate effect sizes in the cognition (g = 0.28), autism symptoms (g = 0.27), and language (g = 0.29) domains. The effect sizes of autism symptoms and language were moderated by country (Western versus Asian countries). However, there were no significant effects observed for the social communication domain. Conclusion: The ESDM intervention significantly improved autism symptoms, language, and cognition. The effect sizes of autism symptoms and language were larger in Asian countries than in Western countries.

Spending on Young Children With Autism Spectrum Disorder in Employer-Sponsored Plans, 2011-2017

OBJECTIVE

Rapid increases in the prevalence of autism spectrum disorder (ASD) and increased access to intensive behavioral interventions have likely increased health care spending. This study estimated recent changes in spending among privately insured children with and without current ASD.

METHODS

A repeated cross-sections analysis of 2011-2017 claims data from large-employer-sponsored health plans assessed changes in annual expenditures by service type for children ages 3-7 enrolled for ≥1 year and with two or more claims with ASD billing codes within a calendar year and for all other children.

RESULTS

Mean spending per child with a current-year ASD diagnosis increased by 51% in 2017 U.S. dollars, from roughly $13,000 in 2011 to $20,000 in 2017. Among children who did not meet the current-year ASD case definition, per-child spending increased by 8%. Spending on children with ASD accounted for 41% of spending growth for children ages 3-7 during 2011-2017. Outpatient behavioral intervention-related spending per child with ASD increased by 376%, from $1,746 in 2011 to $8,317 in 2017; spending on all other services increased by 2%. Their share of behavioral intervention-related spending increased from 13.2% in 2011 to 41.7% in 2017. In 2011, 2.5% of children with current-year ASD diagnoses incurred ≥$20,000 in outpatient behavioral intervention-related spending, which increased to 14.4% in 2017.

CONCLUSIONS

During 2011-2017, spending increased six times as much for privately insured children ages 3-7 with current-year ASD as for children without ASD, largely from increased behavioral intervention-related spending. One in seven children received at least $20,000 in services in 2017.

Autism screening and conditional cash transfers in Chile: Using the Quantitative Checklist (Q-CHAT) for early autism detection in a low resource setting

LAY ABSTRACT

Getting a diagnosis of autism can take long, because autism is different across people, but also because it depends on the way it gets diagnosed. This is especially important in poorer countries or in the case of poor people living in wealthier countries that have significant groups of disadvantaged communities. We adapted a 10-item version of the Q-CHAT-25 questionnaire for use in routine health check-ups programme in Chile and recruited 287 participants under the age of three divided into three groups: Controls (125), Developmental Delay (149) and Autism Spectrum Condition (13). Our results show that a short questionnaire for autism screening can be successfully applied in a health-check programme in poor resource settings. Our results show that our questionnaire had good overall performance, not different to its longer version, the Q-CHAT-25. Our questionnaire was autism specific, with good sensitivity and reliability, and is suitable to be used in a screening setting. This study provides evidence that the implementation of Autism Spectrum Condition screening programmes using the Q-CHAT-10 provides value for money and improves diagnosis of Autism Spectrum Condition in those participating in routine health check-up programmes in developing countries or poor areas of wealthy countries.