Challenging Case: Leveraging Community Partnerships to Address Barriers to Care for Students with Autism.

CASE: Sam is an 11-year-old young boy with autism spectrum disorder (ASD), unspecified anxiety disorder, and attention-deficit/hyperactivity disorder, combined presentation. He was initially diagnosed with ASD at 6 years of age after evaluation by a developmental-behavioral (DB) pediatrician. He presents to the DB pediatrics clinic to reestablish care. He established care with psychiatry 5 months ago after his school referred him to a hospital-school-community telepartnership bridge program following statements of self-harm and numerous concerns with his behavior, including elopement.Sam currently receives special education support under the classifications of "Emotional Disturbance" and "Speech Impairment." His parents report significant challenges with having his medical diagnosis of autism recognized by the school, which has impeded him receiving educational support as a student with autism. This has resulted in Sam being penalized for challenging behaviors related to his neurodevelopmental disorder. He is not currently making meaningful progress in the school setting. Sam currently demonstrates avoidance, physical and verbal aggression, and difficulty adapting to change across settings. In addition to difficulties advocating for more individualized support at school, Sam has never received applied behavior analysis (ABA) therapy because of challenges obtaining insurance approval. There are no additional barriers to accessing care, such as language, geographic, or socioeconomic factors.Sam's visit to reestablish care with DB pediatrics consisted of an individual clinician evaluation model. The Childhood Autism Rating Scale, Second Edition, (CARS-2) and Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), were administered, and Sam continued to meet DSM-5 criteria for ASD following re-evaluation. A new referral for ABA therapy was submitted. Shortly afterward, his family received an insurance denial letter specifying that additional developmental testing was needed before ABA therapy would be approved. His clinician called the insurance company to appeal this decision but was unsuccessful. Sam was then seen by the DB pediatrics embedded psychologist, who completed additional testing, including assessment of cognitive functioning, administration of the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), and autism-specific rating scales. This process led to further delays in access to ABA services. Throughout this process, the parents reported feeling helpless and frustrated given the barriers faced in receiving appropriate services. What are your next steps to advocate for supports through the school and insurance company?

Parent-Reported Problems Accessing Mental Health Services Among a National Sample of Youth with Autism Spectrum Disorder and Anxiety.

OBJECTIVE: The objective of this study was to identify factors associated with parent-reported problems accessing needed mental health services (MHS) in youth with autism spectrum disorder and anxiety. METHODS: This study is a secondary analysis using the National Survey of Children's Health 2016 to 2017 data sets with multivariable logistic regression. Subjects are 6 to 17 year olds with parent-reported autism spectrum disorder (ASD) and anxiety. Outcome is parent-reported challenge accessing needed mental health treatment, dichotomized to not a problem versus problem. Covariates included race/ethnicity, intellectual disability, insurance, medical home, poverty level, and parent education level. RESULTS: The sample included 568 youth with ASD and anxiety-78% male subjects, mean age 12.5 years, and 63% White, non-Hispanic. Fifty-three percent of youth with ASD and anxiety had parent-reported problems accessing needed MHS. Lack of medical home (adjusted odds ratio [aOR] 5.97, 95% confidence interval [CI] [2.72-13.09]) and coexisting intellectual disability (aOR 2.23, 95% CI [1.08-4.60]) were significantly associated with problems accessing MHS. Reported family incomes at 0% to 99% and 100% to 199% of the federal poverty level as compared with family income at 400% federal poverty level or above (aOR 0.32, 95% CI [0.11-0.94] and aOR 0.35, 95% CI [0.13-0.95], respectively) was associated with decreased problems accessing MHS. CONCLUSION: In this nationally representative study, more than half of youth with ASD and anxiety had parent-reported problems accessing needed MHS. Lack of a medical home, co-occurring intellectual disability, and higher socioeconomic status (SES) are associated with problems accessing MHS. Therefore, policies to support the medical home; increase mental health supports available for those with ASD, anxiety, and coexisting intellectual disability; and support access for all SES levels may increase mental health access.

Use of Telehealth in Fellowship-Affiliated Developmental Behavioral Pediatric Practices During the COVID-19 Pandemic.

OBJECTIVE: This study aims to describe the use of telehealth in developmental behavioral pediatric (DBP) fellowship-affiliated practices during the coronavirus disease 2019 (COVID-19) global pandemic. METHODS: An electronic survey was disseminated to all DBP fellowship-associated practice locations to determine the use of telehealth in DBP care provision, before and since the beginning of the COVID-19 pandemic. We analyzed responses using descriptive statistics. RESULTS: A total of 35 of 42 eligible practice sites responded (83% response rate). Most sites (51.4%) reported using telehealth less than once per month before the COVID-19 pandemic. Since the onset of COVID-19, 100% of programs reported conducting video-based telehealth visits multiple days per week. Most sites reported conducting evaluations and follow-up visits for attention-deficit/hyperactivity disorder, autism spectrum disorder, behavioral concerns, developmental delay, genetic disorders, and learning disability. Most sites were able to continue medication management by telehealth (>88%), offer interpreter services for families with limited English proficiency participating in telehealth visits (>90%), and incorporate trainees and interdisciplinary team members in telehealth visits (>90%). Greater variability was observed in sites' ability to collect telehealth practice evaluation measures. CONCLUSION: Most sites are providing evaluations and ongoing care for DBP conditions through telehealth. The rapid adoption of telehealth can have ramifications for the way that DBP care is delivered in the future; therefore, it is imperative to understand current practice patterns and variations to determine the best use of telehealth.

Depressive Symptoms and Suicidality in Adolescents Using e-Cigarettes and Marijuana: A Secondary Data Analysis From the Youth Risk Behavior Survey.

OBJECTIVES: E-cigarette use has increased dramatically among adolescents in the past 5 years alongside a steady increase in daily use of marijuana. This period coincides with a historic rise in depression and suicidal ideation among adolescents. In this study, we describe the associations between e-cigarette and marijuana use and depressive symptoms and suicidality in a large nationally representative sample of high school students. METHODS: We used data from the 2 most recent waves (2015 and 2017) of the Youth Risk Behavior Survey. Our sample (n = 26,821) included only participants with complete information for age, sex, race/ethnicity, and exposure to e-cigarettes and marijuana (89.5% of survey respondents). We performed multivariate logistic regressions to explore the associations between single or dual use of e-cigarette and marijuana and depressive and suicidal symptoms in the past year adjusting for relevant confounders. RESULTS: E-cigarette-only use was reported in 9.1% of participants, marijuana-only use in 9.7%, and dual e-cigarette/marijuana use in 10.2%. E-cigarette-only use (vs no use) was associated with increased odds of reporting suicidal ideation (adjusted odds ratio [AOR]:1.23, 95% CI 1.03-1.47) and depressive symptoms (AOR: 1.37, 95% CI 1.19-1.57), which was also observed with marijuana-only use (AOR: 1.25, 95% CI 1.04-1.50 and AOR: 1.49, 95% CI 1.27-1.75) and dual use (AOR: 1.28, 95% CI 1.06-1.54 and AOR: 1.62, 95% CI 1.39-1.88). CONCLUSIONS: Youth with single and dual e-cigarette and marijuana use had increased odds of reporting depressive symptoms and suicidality compared to youth who denied use. There is a need for effective prevention and intervention strategies to help mitigate adverse mental health outcomes in this population.