Although the American Academy of Pediatrics recommends screening for autism spectrum disorder (ASD) for all young children, disparities in ASD diagnosis and intervention in minority children persist. ...One potential contributor to disparities could be whether physicians take different actions after an initial positive screen based on patient demographics. This study estimated factors associated with physicians completing the follow-up interview for the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT-F), and referring children to diagnostic services, audiology, and Early Intervention (EI) immediately after a positive screen.
Children seen in a large primary care network that has implemented universal ASD screening were included if they screened positive on the M-CHAT parent questionnaire during a 16-30 month well child visit (N = 2882). Demographics, screening results, and referrals were extracted from the electronic health record.
Children from lower-income families or on public insurance were more likely to have been administered the follow-up interview. Among children who screened positive, 26% were already in EI, 31% were newly referred to EI, 11% were referred each to audiology and for comprehensive ASD evaluation. 40.2% received at least one recommended referral; 3.7% received all recommended referrals. In adjusted multivariable models, male sex, white versus black race, living in an English-speaking household, and having public insurance were associated with new EI referral. Male sex, black versus white race, and lower household income were associated with referral to audiology. Being from an English-speaking family, white versus Asian race, and lower household income were associated with referral for ASD evaluation. A concurrent positive screen for general developmental concerns was associated with each referral.
We found low rates of follow-up interview completion and referral after positive ASD screen, with variations in referral by sex, language, socio-economic status, and race. Understanding pediatrician decision-making about ASD screening is critical to improving care and reducing disparities.
Sleep problems are common in children with autism spectrum disorder (ASD), with 40% to 80% prevalence. Common disorders include insomnia, parasomnias, and circadian rhythm sleep-wake disorders. These ...problems have a multifactorial etiology and can both exacerbate and be exacerbated by core ASD symptoms. Sleep problems also impact the health and quality of life of both patients and their caregivers. All children with autism should be regularly screened for sleep problems and evaluated for co-occurring medical contributors. Behavioral interventions with caregiver training remain first-line treatment for sleep disorders in both neurotypical and neurodiverse youth.
1. The question of when to monitor and when to act is fundamental to applied ecology and notoriously difficult to answer. Value of information (VOI) theory holds great promise to help answer this ...question for many management problems. However, VOI theory in applied ecology has only been demonstrated in singledecision problems and has lacked explicit links between monitoring and management costs. 2. Here, we present an extension of VOI theory for solving multi-unit decisions of whether to monitor before managing, while explicitly accounting for monitoring costs. Our formulation helps to choose the optimal monitoring/management strategy among groups of management units (e.g. species, habitat patches) and can be used to examine the benefits of partial and repeat monitoring. 3. To demonstrate our approach, we use case-simulated studies of single-species protection that must choose among potential habitat areas, and classification and management of multiple species threatened with extinction. We provide spreadsheets and code to illustrate the calculations and facilitate application. Our case studies demonstrate the utility of predicting the number of units with a given outcome for problems with probabilities of discrete states and the efficiency of having a flexible approach to manage according to monitoring outcomes. 4. Synthesis and applications. The decision to act or gather more information can have serious consequences for management. No decision, including the decision to monitor, is risk-free. Our multi-unit expansion of Value of Information theory can reduce the risk in monitoring/acting decisions for many applied ecology problems. While our approach cannot account for the potential value of discovering previously unknown threats or ecological processes via monitoring programmes, it can provide quantitative guidance on whether to monitor before acting, and which monitoring/management actions are most likely to meet management objectives.
Anxiety is one of the most prevalent co-occurring symptoms in youth with autism spectrum disorder (ASD). The assessment and treatment recommendations proposed here are intended to help primary care ...providers with the assessment and treatment of anxiety in ASD.
The Autism Speaks Autism Treatment Network/Autism Intervention Research on Physical Health Anxiety Workgroup, a multidisciplinary team of clinicians and researchers with expertise in ASD, developed the clinical recommendations. The recommendations were based on available scientific evidence regarding anxiety treatments, both in youth with ASD and typically developing youth, and clinical consensus of the workgroup where data were lacking.
Assessment of anxiety requires a systematic approach to evaluating symptoms and potential contributing factors across various developmental levels. Treatment recommendations include psychoeducation, coordination of care, and modified cognitive-behavioral therapy, particularly for children and adolescents with high-functioning ASD. Due to the limited evidence base in ASD, medications for anxiety should be prescribed cautiously with close monitoring of potential benefits and side effects.
Assessment and treatment of clinical anxiety in youth with ASD require a standardized approach to improve outcomes for youth with ASD. Although this approach provides a framework for clinicians, clinical judgment is recommended when making decisions about individual patients.
Sleep difficulties are common in children with autism spectrum disorders, with wide-ranging effects on the child's daytime behavior. We reviewed data within our Autism Speaks Autism Treatment Network ...Registry to determine the prevalence of sleep difficulties and patterns of medication use.
Data from 1518 children ages 4 to 10 years were analyzed to determine the number of children documented to have sleep difficulties by parent-completed questionnaires and clinician-completed forms and how these findings related to the use of sleep medications.
The Children's Sleep Habits Questionnaire total score was ≥41 (associated with clinically significant sleep problems in past research) in 71% of children. The prevalence of sleep diagnoses was less frequent (30% of children aged 4-10 years; P < .0001). Medications for sleep were prescribed in 46% of 4- to 10-year-olds given a sleep diagnosis. The most common medication used for sleep was melatonin followed by α-agonists, with a variety of other medications taken for sleep (anticonvulsants, antidepressants, atypical antipsychotics, and benzodiazepines). Children taking medications for sleep had worse daytime behavior and pediatric quality of life than children not taking sleep medications.
Parent concerns about sleep may not be reflected in the information gathered during a clinic visit, supporting the need to develop screening practice pathways for sleep in autism spectrum disorders. Furthermore, many medications taken for sleep have adverse effects, supporting the need for evidence-based interventions in this population.
This study systematically examined the efficacy and safety of psychopharmacological and non-psychopharmacological treatments for anxiety in youth with autism spectrum disorders (ASD). Four ...psychopharmacological, nine cognitive behavioral therapy (CBT), and two alternative treatment studies met inclusion criteria. Psychopharmacological studies were descriptive or open label, sometimes did not specify the anxiety phenotype, and reported behavioral activation. Citalopram and buspirone yielded some improvement, whereas fluvoxamine did not. Non-psychopharmacological studies were mainly randomized controlled trials (RCTs) with CBT demonstrating moderate efficacy for anxiety disorders in youth with high functioning ASD. Deep pressure and neurofeedback provided some benefit. All studies were short-term and included small sample sizes. Large scale and long term RCTs examining psychopharmacological and non-psychopharmacological treatments are sorely needed.
In this retrospective cohort study using data from an integrated primary care and subspecialty network, we examined medical records of children seen in primary care at eligible autism spectrum ...disorder (ASD) screening ages and followed through at least 4 years of age. We examined the prevalence of ASD; age of first documented ASD diagnosis; and whether the prevalence and age of documented diagnosis varied by race, ethnicity, socio-economic status (SES) and site of care (urban versus suburban/rural). The prevalence of ASD across the cohort was 3.2%, with a median age of diagnosis of 3.93 years. ASD prevalence was unexpectedly higher among Asian children, non-Hispanic Black children, children with higher Social Vulnerability Index scores (a neighborhood-level proxy of socio-economic risk), and children who received care in urban primary care sites. There were no statistically significant differences in age at which ASD diagnosis was documented across socio-demographic groups. Receiving primary care at an urban site accounted for most other socio-demographic differences in ASD prevalence rates, except among Asian children, who were found to have higher adjusted odds of ASD diagnosis compared to White children (aOR = 1.82, p < .001). Determining what clinical-, individual- or systems-level factors contribute to ASD diagnosis remains important to improve equity.
Lay Abstract
Historically, children from non-Hispanic Black and Hispanic backgrounds, those from lower-income families, and girls are less likely to be diagnosed with autism spectrum disorder. Under-identification among these historically and contemporaneously marginalized groups can limit their access to early, autism spectrum disorder-specific interventions, which can have long-term negative impacts. Recent data suggest that some of these trends may be narrowing, or even reversing. Using electronic health record data, we calculated autism spectrum disorder prevalence rates and age of first documented diagnosis across socio-demographic groups. Our cohort included children seen at young ages (when eligible for screening in early childhood) and again at least after 4 years of age in a large primary care network. We found that autism spectrum disorder prevalence was unexpectedly higher among Asian children, non-Hispanic Black children, children with higher Social Vulnerability Index scores (a measure of socio-economic risk at the neighborhood level), and children who received care in urban primary care sites. We did not find differences in the age at which autism spectrum disorder diagnoses were documented in children’s records across these groups. Receiving primary care at an urban site (regardless of location of specialty care) appeared to account for most other socio-demographic differences in autism spectrum disorder prevalence rates, except among Asian children, who remained more likely to be diagnosed with autism spectrum disorder after controlling for other factors. We must continue to better understand the process by which children with autism spectrum disorder from traditionally under-identified and under-served backgrounds come to be recognized, to continue to improve the equity of care.
Plans for expanding protected area systems (prioritizations) often aim to facilitate connectivity. To achieve this, many approaches—based on different assumptions and datasets—have been developed. ...However, little is known about how such approaches influence prioritizations.
We examine eight approaches that aim to promote connectivity in prioritizations. Using Washington State (USA) and its avifauna as a case study, we generated prioritizations that aimed to meet species' representation targets and promote connectivity by (a) maximizing total area; (b) further maximizing species representation; (c) minimizing boundary length; and connecting areas based on (d) minimizing human pressure, (e) minimizing naturalness‐based landscape resistance, (f) minimizing focal species landscape resistance, (g) minimizing habitat heterogeneity and (h) maximizing environmental similarity. We controlled for total expenditure, species' representation, and existing land use policies to enable comparisons among prioritizations. We then used a hierarchical cluster analysis to compare prioritizations, based on which areas they selected. We also evaluated how well each approach facilitated connectivity as measured by the other approaches.
We found that different approaches for promoting connectivity can lead to very different or very similar prioritizations, depending on their underlying assumptions. In particular, the boundary length approach—which is widely used in systematic conservation planning—resulted in a prioritization that was highly dissimilar to all other prioritizations. Surprisingly, approaches based on very different underlying assumptions produced similar prioritizations, such as maximizing total area and minimizing focal species landscape resistance approaches. Moreover, when comparing the prioritizations based on the level of connectivity they could facilitate, we found that none of the prioritizations facilitated a high level of connectivity for all eight approaches.
Synthesis and applications. We recommend carefully considering the assumptions and limitations that underpin approaches for promoting connectivity. Our findings demonstrate that different connectivity approaches can produce marked differences in priorities and, in turn, produce trade‐offs between different approaches. Indeed, despite the ubiquity of the boundary length approach, practitioners might find that other approaches can better achieve conservation objectives. Practitioners can use our methodology for comparing different connectivity approaches to help to navigate trade‐offs among them.
We recommend carefully considering the assumptions and limitations that underpin approaches for promoting connectivity. Our findings demonstrate that different connectivity approaches can produce marked differences in priorities and, in turn, produce trade‐offs between different approaches. Indeed, despite the ubiquity of the boundary length approach, practitioners might find that other approaches can better achieve conservation objectives. Practitioners can use our methodology for comparing different connectivity approaches to help to navigate trade‐offs among them.
Purpose of Review
This article discusses common issues surrounding transition to adulthood in youth with autism spectrum disorder (ASD). We review recent evidence on co-occurring medical and mental ...health conditions and topics of education and employment, sexuality and relationships, independent living, and financial support.
Recent Findings
Transitioning individuals with ASD have increased risk for several medical and behavioral health comorbidities and should be routinely screened for co-occurring conditions. Evidence on interventions for mental health disorders is limited but emerging, particularly with respect to mindfulness training and cognitive behavioral therapy. Many autistic adults or their families express a desire for independent living, participation in education/employment, and intimacy and social relationships, but they often lack skills and/or resources to successfully achieve these outcomes.
Summary
The time of transition to adulthood for adolescents with ASD is an opportunity for physicians to provide anticipatory guidance and necessary supports around issues of community participation. To allow time for planning, these discussions should occur well before the child reaches adulthood. Clinicians should also routinely screen for and address medical and/or behavioral health comorbidities.
Objectives
Very little research has explored the complex relation between ACEs, poverty, and obesity in young children with neurodevelopmental delays. The purpose of this study was to examine whether ...ACEs predicted overweight/obesity in young children with neurodevelopmental delays after income was taken into account, and to examine the extent to which poverty moderated the relation between ACEs and overweight/obesity.
Methods
Participants were 180 children between the ages of 2 and 7 who were referred for a developmental and behavioral pediatrics evaluation (mean age 4.5 years old; 76% male) in the northeast United States. Parents completed a survey about their child’s ACEs, and an electronic health record review was conducted.
Results
ACEs did not directly predict obesity after income was taken into account. However, poverty moderated the relation between ACEs and obesity, such that when children experienced no ACEs, there was no difference in the rates of obesity between children above and below the poverty threshold. Among children who did experience ACEs, children who also lived in poverty had higher rates of obesity than children who did not live in poverty.
Conclusions for Practice
Children with neurodevelopmental delays are at greater risk for overweight/obesity if they experience both risk factors of being in poverty and of experiencing ACEs. When conducting screenings, providers should understand that the impact of ACEs may vary by contextual factors such as poverty. More research is needed to identify factors that can mitigate the impact of poverty and ACEs on children’s physical health.
PDF
