Ethnic Disparities in Autism Spectrum Disorder Screening and Referral: Implications for Pediatric Practice ABSTRACT: Objective: Autism spectrum disorder (ASD) screening completion rates are often low despite their validity and influence on earlier intervention and positive treatment outcomes. This study sought to examine the use of one ASD screening tool, the Modified Checklist for Autism in Toddlers-Revised (MCHAT-R), in a racially and ethnically diverse urban pediatric clinic to review potential disparities within screening rates and referral practices. Methods: A retrospective chart review was conducted for children (N = 999) within the ages of 17 to 34 months seen for a well-child appointment at one of 3 pediatric clinics: a general pediatric clinic, resident pediatric clinic, and Hispanic pediatric clinic. Results: MCHAT-R screening completion rates were low for all clinics. There were no significant differences in MCHAT-R screening completion based on ethnicity; however, the percentage of children screening positive on the MCHAT-R was significantly higher for Hispanic versus non-Hispanic children. Referral practices were highly variable across positive screenings, and few children received the appropriate combination of referrals. Conclusion: Ethnic disparities in ASD positive screening rates and inconsistent referrals represent a critical issue in current pediatric practice. There is a great need for the development of more culturally sensitive ASD screening instruments. Additionally, to help increase ASD screening rate and accuracy, as well as consistency in referrals, greater emphasis is needed on professional training, parental education, and technology use within pediatric clinics.

Racial and Ethnic Disparities in Autism-Related Health and Educational Services ABSTRACT: Objective: The objective of this study is to measure racial and ethnic disparities in autism-related services among U.S. children with parent-reported autism spectrum disorder (ASD). Methods: Using the 2011 Survey of Pathways to Diagnosis and Services, we analyzed parent-reported data on 1420 children with current ASD in the nationally representative sample. An estimation method consistent with the Institute of Medicine's definition of health care disparities is used to measure racial and ethnic disparities. Results: The findings revealed Latino-white disparities in the percentage of children currently using school-based occupational and physical therapy and Latino-white and “other race”-white disparities in the percentage of children using physical therapy outside of school. There were no statistically significant black-white disparities. Instead, the study found that the percentage of black children with ASD receiving school-based services was 8 points higher than that of white children (p < 0.04). Factors unrelated to the need for autism services were largely unassociated with the receipt of services. Conclusion: The findings provide a partial baseline and identify a need for further examination of the source of existing disparities and the lack of disparities found for specific services and minority groups.

Quantitative Evaluation of Content and Age Concordance Across Developmental Milestone Checklists ABSTRACT: Objective: Clinicians and caregivers rely on milestone checklists as tools for tracking a child's development. In addition, medical students and residents use milestone checklists to learn about normal child development. However, there are multiple published milestone checklists that vary qualitatively in structure and content, hindering their effective use in developmental surveillance and medical education. This project systematically evaluated the consistency and variability between commonly used milestone checklists. Methods: A team of child psychologists and developmental pediatricians reviewed a total of 1094 milestones derived from 4 published checklists (2 developed for providers, 2 developed for caregivers) to create a comprehensive set of 728 discrete developmental observations, with each observation mapped to corresponding milestones. This observation-milestone relational database was then used to determine the degree of content overlap and milestone age range concordance across milestone checklists. Results: Of the 728 discrete developmental observations, 40 (5.5%) were mapped to milestones in all 4 milestone checklists, and an additional 90 (12.4%) were mapped to 3 checklists. Among these 40 “universal” observations, most (42.5%) were in the motor domain. Of those 130 observations mapped to milestones in at least 3 of the 4 checklists, 26.9% (35/130) were mapped to milestones that were discordant in their associated age range. Conclusion: Four commonly used developmental milestone checklists were found to have limited overlap in content, and those that overlapped were inconsistent in their associated age ranges. The resulting observation-milestone relational database could be used to further validate age estimates of milestones and facilitate milestone surveillance through the electronic health record.

The Relationship Among Screen Use, Sleep, and Emotional/Behavioral Difficulties in Preschool Children with Neurodevelopmental Disorders ABSTRACT: Objective: Despite evidence that excessive screen use may contribute to negative health, developmental, emotional, and behavioral outcomes, more children are engaging in increasing amounts of screen-related activities. For children with neurodevelopmental conditions, increased screen use could exacerbate emotional/behavioral difficulties (EBDs) by interfering with sleep quantity and quality. Aims: This study examined the possible mediating role of sleep in the relationship between screen use and EBDs in preschool children with neurodevelopmental disorders (NDDs) clinically referred to a child development center in Singapore. Methods: A screen use questionnaire developed for the purposes of the present study, the Children's Sleep Habits Questionnaire, and the Strengths and Difficulties Questionnaire were completed by 367 caregivers of 2- to 5-year-old children with NDDs (39.5% autism spectrum disorder; 36.8% speech-language disorders; 23.7% others). Results: Average daily screen use duration was 3.98 hours, with 93.9% exceeding 1 hour of screen time daily. 57.7% of children had screen devices in their bedrooms, while 52% commenced screen use at the age of 18 months or earlier. Sleep problems fully mediated the relationship between the number of bedroom screen devices and children's EBDs, as well as between the age of first screen use and EBDs, but not between hours of screen use and EBDs. Controlling for age, developmental level, and family income, children who started using screens earlier than 18 months and who had screen devices in their bedrooms had significantly more sleep problems and EBDs than those without. Conclusion: Children with neurodevelopmental conditions may have more difficulties disengaging from screen devices in their bedrooms, and an earlier age of screen exposure may contribute to more chronic disruption of sleep.

Early Shared Reading Is Associated with Less Harsh Parenting ABSTRACT: Objective: Shared reading is believed to enhance parent-child relationships, but the extent to which it reduces harsh parenting is understudied. Associations between early shared reading and subsequent harsh parenting were investigated. Methods: Data from a national urban birth cohort were used to estimate associations between mother-reported shared reading at ages 1 and 3 years and harsh parenting—based on a composite of psychological and physical aggression subscales of a validated self-report instrument—when the children were at ages 3 and 5 years. The authors used multivariable linear regression and generalized estimating equations to account for repeated observations. Given potential inverse associations between shared reading and child disruptive behaviors, which can trigger harsh parenting, the authors investigated the extent to which children's behavior at age 3 years mediated the association between shared reading at age 1 year and harsh parenting at age 5 years. Results: This study included 2165 mother-child dyads. Thirty-four percent and 52% of mothers reported daily reading at ages 1 and 3 years. In adjusted models, shared reading at age 1 year was associated with less harsh parenting at age 3 years. Similarly, shared reading at age 3 years was associated with less harsh parenting at age 5 years. These associations remained significant in lagged repeated-measures models. Decreased disruptive behaviors partially mediated the association between shared reading at age 1 year and harsh parenting at age 5 years. Conclusion: Shared reading predicted less harsh parenting in a national urban sample. These findings suggest that shared reading contributes to an important aspect of the parent-child relationship and that some of the association operates through enhanced child behaviors.

Shared Reading Practices and Early Literacy Promotion in the First Year of Life ABSTRACT: Limited research exists on family reading practices, the impact of counseling, and book distribution in the first 6 months of life, despite recommendations from the American Academy of Pediatrics and Reach Out and Read promoting shared reading from birth. Objective: To describe infant home reading trajectories and environments in the first year and to assess whether receiving books starting in the newborn period, compared with starting at 6 months, alters these trajectories. Methods: Two study groups were enrolled in a quasi-experimental sequential cohort study; both groups received shared reading counseling starting in the newborn period and completed surveys throughout the first year. The Standard group received books starting at 6 months, whereas the Early Books group received books starting at 2 weeks. Reading trajectories were assessed both overall and between the study groups. Results: At the 2-week visit, less than half of families in each group had started shared reading with their infant, which rose to >97% by 12 months. Approximately two-thirds of families owned >10 children's books at 2 weeks, which increased to >80% at 12 months. Incorporating shared reading into bedtime routines also increased during the first year. Early versus standard book distribution did not alter these trajectories. Conclusion: Over the first year of life, families almost universally initiated shared reading and increased the number of books in the home. Reading habits established during this time were maintained in both groups. Literacy promotion beginning at the earliest well-child visits may help establish routines that will persist throughout childhood.

Executive Function Profiles at Home and at School in 11-Year-Old Very Low Birth Weight or Very Low Gestational Age Children ABSTRACT: Objective: Executive function (EF) problems of children born at very low birth weight (VLBW; ≤1500 g) or very low gestational age (VLGA; <32 gestational weeks) may present differently at school compared to the home environment. Ecological assessment of EF including parent- and teacher-rated profiles and associated risk factors of 11-year-old children born at VLBW or VLGA was evaluated. Methods: A total of 125 VLBW or VLGA children and 132 controls were assessed using the Behavior Rating Inventory of EF, which includes 8 subscales that form the Behavioral Regulation and Metacognition Indexes. For VLBW or VLGA children, full-scale intelligence quotient (IQ) was assessed using the Wechsler Intelligence scale for Children, Fourth Edition. Neonatal data were collected systematically. Results: VLBW or VLGA children with full-scale IQ ≥ 70 had clinically significant problems in the Working Memory subscale at school. Although they had clinically significant problems at home in the Behavioral Regulation Index, the difference disappeared when adjusted for paternal education. Lower gestational age, lower birth weight z-score, surgical necrotizing enterocolitis, low paternal and maternal education, and lower full-scale IQ were identified to be risk factors for higher scores in ecological assessment of EF. Conclusion: VLBW or VLGA children in this cohort exhibit fewer EF problems in ecological assessment of EF compared to previous literature. EF problems of this study population vary by home and school setting and are emphasized in working memory at school. Screening for EF problems in school environment is recommended to target the support.

Traumatogenic Potential of Federal Policy in the Lives of Children No abstract available

Diagnosis and Treatment of Developmental Dyslexia and Specific Learning Disabilities: Primum Non Nocere ABSTRACT: Specific learning disabilities (SLDs) are increasingly being addressed by researchers, schools, and institutions, as shown by the increasing number of publications, guidelines, and incidence statistics. Although SLDs are becoming a major topic in education with the final goal of inclusive schools, consistent drawbacks may emerge, resulting in disadvantages instead of benefits for some children. Overdiagnosis and unnecessary interventions may harm children's neurodevelopment and families' quality of life more than previously thought. In this commentary, we discuss recent understandings, their practical and educational applications, and some considerations of the effects of these choices on children.

Transitions, Suicidality, and Underappreciated Autism Spectrum Disorder in a High School Student CASE: Alex is a 14-year-old Portuguese-American boy with a psychiatric history starting at age 5 who presents to your primary care practice after an insurance change. He was delivered prematurely at 32 weeks and diagnosed with congenital hypothyroidism at the age of 6 weeks and growth hormone deficiency at the age of 2 years; he is in active treatment for both. He otherwise met developmental milestones on time yet continues to have significant fatigue despite adequate sleep and vitamin D supplementation. His family history is remarkable for maternal anxiety, depression, suicidal thoughts, and previous attempted suicide, as well as anxiety, alcoholism, depression, and attention-deficit/hyperactivity disorder (ADHD) in the extended family. Alex has had multiple psychiatric diagnoses by sequential providers. He was diagnosed with generalized anxiety disorder and ADHD by 5 years of age, major depressive disorder by 11 years of age, persistent depressive disorder by 12 years of age, and ultimately disruptive mood dysregulation disorder because of severe and persistent temper outbursts associated with negative mood and behavioral dysregulation, leading to recurrent crisis evaluations. He has been psychiatrically hospitalized twice, in the fifth and seventh grade, for suicidal ideation (SI) and elopement from home, respectively. He recently completed a 2-week acute residential placement, during which no medication changes were made. Current medications include escitalopram 20 mg daily, guanfacine 1 mg 3 times daily, sustained release bupropion 100 mg twice daily, levothyroxine, vitamin D, and a weekly somatropin injection. He has not been able to tolerate psychostimulants or nonstimulant agents because of treatment-emergent SI. Now in the ninth grade, he continues to be easily distracted by peers, with impulsive behaviors and reduced self-regulation. Despite receiving special education services since the fifth grade, his academic performance has been poor, and he has limited motivation. Previous testing indicated average in an intelligence quotient test, with relative deficits in working memory compared with above average strength in fluid reasoning. He dislikes school and has few friends. He has always been noted to be “immature.” He displays temper tantrums at home and school around transitions and behavioral expectations and has complained of feeling “different” and misunderstood by peers in addition to having difficulty reading social cues. His interests include acting and playing Fortnite and other video/computer games. His screen time is limited to 1 to 2 hr/d by the family. As the new clinician, you raise the possibility of undiagnosed autism spectrum disorder as a unifying/underlying diagnosis with his mother, who disagrees and does not consent to additional workup despite your recommendations. How would you proceed with next steps to best support your patient and his family in obtaining further clarifying evaluation?