Cultivating community-based participatory research (CBPR) to respond to the COVID-19 pandemic: an illustrative example of partnership and topic prioritization in the food services industry.

BACKGROUND: As an illustrative example of COVID-19 pandemic community-based participatory research (CBPR), we describe a community-academic partnership to prioritize future research most important to people experiencing high occupational exposure to COVID-19 - food service workers. Food service workers face key challenges surrounding (1) health and safety precautions, (2) stress and mental health, and (3) the long-term pandemic impact. METHOD: Using CBPR methodologies, academic scientists partnered with community stakeholders to develop the research aims, methods, and measures, and interpret and disseminate results. We conducted a survey, three focus groups, and a rapid qualitative assessment to understand the three areas of concern and prioritize future research. RESULTS: The survey showed that food service employers mainly supported basic droplet protections (soap, hand sanitizer, gloves), rather than comprehensive airborne protections (high-quality masks, air quality monitoring, air cleaning). Food service workers faced challenging decisions surrounding isolation, quarantine, testing, masking, vaccines, and in-home transmission, described anxiety, depression, and substance use as top mental health concerns, and described long-term physical and financial concerns. Focus groups provided qualitative examples of concerns experienced by food service workers and narrowed topic prioritization. The rapid qualitative assessment identified key needs and opportunities, with help reducing in-home COVID-19 transmission identified as a top priority. COVID-19 mitigation scientists offered recommendations for reducing in-home transmission. CONCLUSIONS: The COVID-19 pandemic has forced food service workers to experience complex decisions about health and safety, stress and mental health concerns, and longer-term concerns. Challenging health decisions included attempting to avoid an airborne infectious illness when employers were mainly only concerned with droplet precautions and trying to decide protocols for testing and isolation without clear guidance, free tests, or paid sick leave. Key mental health concerns were anxiety, depression, and substance use. Longer-term challenges included Long COVID, lack of mental healthcare access, and financial instability. Food service workers suggest the need for more research aimed at reducing in-home COVID-19 transmission and supporting long-term mental health, physical health, and financial concerns. This research provides an illustrative example of how to cultivate community-based partnerships to respond to immediate and critical issues affecting populations most burdened by public health crises.

Associations Between Depressive Symptoms, Fear of Hypoglycemia, Adherence to Management Behaviors and Metabolic Control in Children and Adolescents with Type 1 Diabetes.

We examined the relationship between two malleable risk factors, depressive symptoms and fear of hypoglycemia, in children and adolescents with Type 1 diabetes and their relationship to two important outcomes, adherence behaviors and metabolic control. To assess this relationship, we used a multidimensional measure of adherence, assessing frequency of both blood glucose monitoring and healthy behaviors including diet and exercise. We predicted that higher levels of depressive symptoms and higher levels of fear of hypoglycemia would be associated with worse metabolic control as mediated by poor adherence. Eighty-three children and adolescents ages 8 to 20 (M = 13.87, SD 3.21) were recruited from March 2014 to October 2014 at an outpatient diabetes clinic in a moderately sized Southeastern city within the USA. Nested models were evaluated using structural equation modeling. Adherence significantly mediated the relationship between depressive symptoms and metabolic control with more depressive symptoms leading to worse metabolic control. Adherence marginally mediated the relationship between fear of hypoglycemia and metabolic control; however, less fear of hypoglycemia was associated with worse metabolic control. In a combined model, adherence continued to significantly mediate the relationship between depressive symptoms and metabolic control, while also independently significantly mediating the relationship between fear of hypoglycemia and metabolic control. This finding was also contrary to the predicted relationship with less fear of hypoglycemia leading to worse metabolic control. The results indicate that youth with fewer depressive symptoms and more fear of hypoglycemia had better adherence to their treatment regimen, which was associated with better metabolic control. The results of this study highlight the importance of screening for depression and fear of hypoglycemia during routine clinic visits to optimize adherence and metabolic control.

Components Analyses of a School-Based Cognitive Behavioral Treatment for Youth Depression.

The current study sought to build upon research on cognitive behavioral therapy (CBT) as the first-line treatment for depressed youth by investigating the effects of the various components of a CBT treatment on changes in depressive symptoms in young female participants. Female participants 9-14 years of age (n = 40; M age = 10.58 years) with a diagnosis of a depressive disorder from the CBT-only treatment condition of a larger randomized clinical trial were included in the current study. Participants engaged in a 20-session, 11-week, school-based CBT group intervention (ACTION Treatment; Stark et al., 2006). Depressive symptoms were assessed pre- and posttreatment, and intervention components were coded based on review of audio recordings of treatment sessions. Data were examined using two-level mixed-effects models using hierarchical linear modeling with full maximum likelihood estimation. Results indicated that higher quality behavioral intervention components were associated with greater improvement in posttreatment depression scores, higher quality cognitive intervention components were marginally associated with worsening posttreatment depression scores, and relational intervention components were not associated with depression outcome. Age significantly moderated the relationships between intervention components and depression outcome, with younger female participants benefiting most from higher quality behavioral and relational intervention components. These findings provide preliminary evidence about the differential impact of CBT components on depression treatment outcome for young female participants, with consideration of age as a moderator. This study highlights the importance of continuing to dismantle CBT treatment components for youth depression, as such findings can be used to design more potent, developmentally tailored interventions.

Teacher (Mis)Perceptions of Preschoolers' Academic Skills: Predictors and Associations With Longitudinal Outcomes.

Preschool teachers have important impacts on children's academic outcomes, and teachers' misperceptions of children's academic skills could have negative consequences, particularly for low-income preschoolers. This study utilized data gathered from 123 preschool teachers and their 760 preschoolers from 70 low-income, racially diverse centers. Hierarchical linear modeling was utilized to account for the nested data structure. Even after controlling for children's actual academic skill, older children, children with stronger social skills, and children with fewer inattentive symptoms were perceived to have stronger academic abilities. Contrary to hypotheses, preschoolers with more behavior problems were perceived by teachers to have significantly better pre-academic abilities than they actually had. Teachers' perceptions were not associated with child gender or child race/ethnicity. Although considerable variability was due to teacher-level characteristics, child characteristics explained 42% of the variability in teachers' perceptions about children's language and pre-literacy ability and 41% of the variability in teachers' perceptions about mathability. Notably, these perceptions appear to have important impacts over time. Controlling for child baseline academic skill and child characteristics, teacher perceptions early in the preschool year were significantly associated with child academic outcomes during the spring for both language and pre-literacy and math. Study implications with regard to the achievement gap are discussed.

Social cognitions, distress, and leadership self-efficacy: associations with aggression for high-risk minority youth.

Urban ethnic minority youth are often exposed to high levels of aggression and violence. As such, many aggression intervention programs that have been designed with suburban nonethnic minority youth have been used or slightly adapted in order to try and meet the needs of high-risk urban youth. The current study contributes to the literature base by examining how well a range of social-cognitive, emotional distress and victimization, and prosocial factors are related to youth aggression in a sample of urban youth. This study utilized data gathered from 109 9- to 15-year-old youth (36.7% male; 84.4% African American) and their parents or caregivers. A series of hierarchical multiple regressions were fit predicting youth aggression from social-cognitive variables, victimization and distress, and prosocial variables, controlling for youth gender and age. Each set of variables explained a significant and unique amount of the variance in youth aggressive behavior. The full model including all predictors accounted for 41% of the variance in aggression. Models suggest that youth with stronger beliefs supportive of violence, youth who experience more overt victimization, and youth who experience greater distress in overtly aggressive situations are likely to be more aggressive. In contrast, youth with higher self-esteem and youth who endorse greater leadership efficacy are likely to be less aggressive. Contrary to hypotheses, hostile attributional bias and knowledge of social information processing, experience of relational victimization, distress in relationally aggressive situations, and community engagement were not associated with aggression. Our study is one of the first to address these important questions for low-income, predominately ethnic minority urban youth, and it has clear implications for adapting aggression prevention programs to be culturally sensitive for urban African American youth.

Developing measures of community-relevant outcomes for violence prevention programs: a community-based participatory research approach to measurement.

Community-Based Participatory Research is a research paradigm that encourages community participation in designing and implementing evaluation research, though the actual outcome measures usually reflect the "external" academic researchers' view of program effect and the policy-makers' needs for decision-making. This paper describes a replicable process by which existing standardized psychometric scales commonly used in youth-related intervention programs were modified to measure indicators of program success defined by community partners. This study utilizes a secondary analysis of data gathered in the context of a community-based youth violence prevention program. Data were retooled into new measures developed using items from the Alabama Parenting Questionnaire, the Hare Area Specific Self-Esteem Scale, and the Youth Asset Survey. These measures evaluated two community-defined outcome indicators, "More Parental Involvement" and "Showing Kids Love." Results showed that existing scale items can be re-organized to create measures of community-defined outcomes that are psychometrically reliable and valid. Results also show that the community definitions of parent or parenting caregivers exemplified by the two indicators are similar to how these constructs have been defined in previous research, but they are not synonymous. There are nuanced differences that are important and worthy of better understanding, in part through better measurement.

The association between forms of aggression, leadership, and social status among urban youth.

While much prior research has documented the negative associations between aggression, peer relationships, and social skills, other research has begun to examine whether forms of aggression also may be associated with prosocial skills and increased social status. However, few studies have examined these associations within diverse samples of elementary aged youth. The current study examined the associations between aggression, popularity, social preference, and leadership among 227 urban, ethnic minority (74 % African American, 9 % bi-racial including African American, 12 % other ethnic minorities, and 5 % European American) elementary school youth (average age 9.5 years, 48.5 % female). Results indicated that in an urban, high risk environment, displaying aggressive behaviors was associated with increased perceived popularity, decreased social preference, and, in some cases, increased perceived leadership. The results also suggested gender differences in the association between the forms of aggression (i.e. relational and overt) and popularity. The current study underscores the importance of examining youth leadership along with forms of aggression and social status among urban minority youth. Implications for future research and aggression prevention programming are highlighted.

Parent Predictors of Changes in Child Behavior Problems.

The present study examined whether ineffective discipline, single parent status, social support, parent involvement, and parent depression predicted changes in preschoolers' (N = 129) behavior problems. This study also evaluated whether child sex and ethnicity moderated the relationships between these variables and changes in problem behavior. Parents completed questionnaires at the beginning of the study, and parent, teacher, and observational ratings of children's behavior problems were collected twice during the school year. Parents' own social support predicted improvement for boys and parent depression was associated with worsening symptoms for girls. Single parenthood and parent involvement predicted changes in behavior problems for the sample as a whole. Several significant ethnic differences emerged, highlighting the importance of considering cultural context in studies of parenting and child externalizing behavior.

Parental Child-Rearing Strategies Influence Self-Regulation, Socio-Emotional Adjustment, and Psychopathology in Early Adulthood: Evidence from a Retrospective Cohort Study.

This study examined the association between recollected parental child-rearing strategies and individual differences in self-regulation, socio-emotional adjustment, and psychopathology in early adulthood. Undergraduate participants (N = 286) completed the EMBU - a measure of retrospective accounts of their parents' child-rearing behaviors - as well as self-report measures of self-regulation and socio-emotional adjustment across the domains of eating disorder symptoms, physically risky behavior, interpersonal problems, personal financial problems, and academic maladjustment. A subset of participants also completed the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF). Parental warmth was found to be related to overall better self-regulation and improved interpersonal and academic adjustment. In contrast, both parental rejection and overcontrol were found to be related to general deficits in self-regulation as well as adjustment difficulties and psychopathology. Parental rejection was most closely related to internalizing clinical presentations like anxiety, depression, and somatization, whereas overcontrol was most aligned with increased hypomanic activation and psychoticism. Mediation analyses demonstrated that the relationships between parental child-rearing strategies and socio-emotional adjustment and psychopathology were partially mediated by self-regulation. Future directions are suggested, including basic and translational research related to better understanding the roles of parental child-rearing and self-regulation in the development of internalizing symptoms, activation, and psychotic symptoms.

Enrollment and attendance in a parent training prevention program for conduct problems.

Low levels of enrollment and attendance in parent training programs present major problems for researchers and clinicians. The literature on enrollment and attendance in prevention programs is especially limited, and these constructs may be particularly difficult to address in this context. Further, most previous research has not made the distinction between enrollment and attendance. This study describes predictors of enrollment and attendance in a behavioral parent training program intended to prevent conduct problems in preschoolers. Information was gathered from 106 preschoolers, their parents, and their teachers. Parent socioeconomic status (SES), single parent status, ethnicity, child externalizing behavior, parent depressive symptoms, and parent social support were investigated as possible predictors of families' enrollment and attendance. Only 48% of the families that had already provided informed consent and completed demographic questionnaires actually enrolled in the parent training program; parents with lower incomes and lower levels of social support were less likely to enroll. In addition, African-American and Puerto Rican families were less likely to enroll than Caucasian families. The average attendance rate for enrolled parents was 61%; dual parents and parents with children evidencing externalizing behavior problems attended more parent training sessions. Parent depression was not associated with enrollment or attendance. Significant relationships were maintained when controlling for other predictors including SES and when accounting for center-level variance. In addition, three distinct patterns of attendance were observed, which may have practical implications related to retention strategies.

Examining the effectiveness of Trauma Smart® training: Staff satisfaction, knowledge, and attitudes.

Objective: Adverse childhood experiences are linked with poorer physical, social, and psychological well-being, especially for individuals who live in poverty. As adverse childhood experiences accumulate, risk for poor outcomes increases. Therefore, it is imperative that preschools and elementary schools are equipped to prevent and intervene upon traumatic stress. Trauma Smart is an organizational change intervention designed to build trauma-informed knowledge, attitudes, skills, and resources within schools serving young children. Method: The current study evaluates the effectiveness of Trauma Smart staff training in 42 preschools and elementary schools with 2,418 staff using a 1-year, longitudinal, prepost design. Trauma Smart implementation occurred during scale-up, under real world conditions. Satisfaction, posttraining knowledge about trauma-informed approaches, and pre-to-posttraining changes in attitudes favorable to trauma-informed care were evaluated. Results: As hypothesized, staff were highly satisfied with the training (mean ratings indicate 92% satisfied), demonstrated knowledge of core concepts related to trauma-informed care (mean quiz scores were scored 90% correct), and developed more favorable attitudes toward trauma-informed care following training, with medium-large effect sizes. Conclusions: Trauma Smart staff training is feasible, acceptable, and has the potential to improve the knowledge and attitudes relevant to trauma-informed approaches within preschool and elementary school staff, including those who serve children who live in poverty. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Validation of the Attitudes Related to Trauma-Informed Care Scale (ARTIC).

OBJECTIVE: The purpose of the current study is to validate the Attitudes Related to Trauma-Informed Care Scale (ARTIC; Baker et al., 2016), a measure of trauma-informed care (TIC) attitudes for human service/health providers and educators. METHOD: The current study with 1,395 human services/health providers and educators from 17 settings examined the factor structure, reliability, and construct validity of the ARTIC. RESULTS: The 7-factor structure of the ARTIC-45 and the 5-factor structure of the ARTIC-35 were replicated with regard to the absolute fit indices though they failed to meet the cutoff for the incremental fit indices, likely due to the complexity of the measure. Internal consistencies ranged from acceptable to excellent across the instrument's forms, subscales, and versions. Providing support for construct validity, ARTIC scores were predictably related to familiarity with and knowledge about TIC, compassion satisfaction, burnout, and secondary traumatic stress, with effect sizes typically in the medium range. However, predicted relationships between ARTIC scores and training in TIC and trauma-sensitive school elements were not evident. CONCLUSIONS: The ARTIC is a direct, efficient, and cost-effective measure of attitudes related to TIC. This study further demonstrates the reliability of the ARTIC and provides some support for its validity. Evaluating the favorability of staff attitudes about TIC plays a key role in ensuring readiness for, effectiveness of, and sustainability of TIC in systems. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Understanding staff- and system-level contextual factors relevant to trauma-informed care implementation.

Objective: Trauma-informed care (TIC) is increasingly used to address and prevent adverse childhood experiences. However, research on the implementation process of TIC has lagged, limiting its impact and sustainability. The goal of this two-study project was to provide a summary of staff- and system-level contextual factors relevant to TIC implementation. Method: Study 1 was a secondary data analysis of survey data from 760 staff members from human services, health, and education practice settings familiar with TIC. Independent-samples t tests were used to evaluate differences between lower- and higher-implementing organizations on staff- and system-level TIC implementation drivers. These drivers were then coded using the Consolidated Framework for Implementation Research (CFIR). Study 2 was a content analysis of the empirical literature on TIC. Study 2 produced information on the staff- and system-level facilitators of and barriers to TIC implementation, which were then also coded using the CFIR. Results: Study 1 suggested that the attributes of the individuals implementing TIC and the implementation climate of the organization played the most central roles. Study 2 identified available resources and the strength and quality of the evidence underpinning the intervention as important contextual factors for TIC implementation. Conclusion: This study used a well-established framework, the CFIR, to elucidate key contextual factors related to the successful implementation of TIC, with the goal of informing the efforts of researchers, practitioners, and policymakers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trauma-informed care training with HIV and related community service workers: Short and long term effects on attitudes.

Although the experience of trauma is a widespread, global phenomenon, individuals living with HIV, who are two-spirit, lesbian, gay, bisexual, transgender, queer+ (2SLGBTQ+), who use injection drugs, and/or who have marginalized status, are disproportionately affected (Harris & Fallot, 2006; Hopper, Bassuk, & Olivet, 2009; Seedat, 2012). The need for trauma competent service provision, meaning integrating psychoeducation about trauma, and knowledge of its prevalence, impact, and outcomes, is clear. Numerous HIV service and affiliated agencies in Ontario requested a Trauma-Informed Care workshop for their staff and volunteers, and the current project reports on the outcomes of this workshop. There were 150 community, health, and social service providers in the HIV, hepatitis C, LGBTQ, harm reduction, and related sectors who participated in a full- or half-day Trauma-Informed Care workshop. Participants completed the Attitudes Related to Trauma-Informed Care scale (ARTIC-10) at preworkshop, postworkshop, and at 6-month follow-up, as well as a brief phone interview. There was a significant increase in ARTIC scores, indicating more favorable attitudes toward trauma-informed care, from preworkshop (M = 58.01, SE = 0.64) to postworkshop (M = 61.73, SE = 0.67), M = -3.72, BCa 95% confidence interval [-4.65, -2.82], t(149) = -7.79, p < .001, resulting in a medium-sized effect, d = 0.48. These gains were maintained at follow-up. Results were complemented by participant interviews. These results demonstrate that a brief workshop on Trauma-Informed Care can improve attitudes relatively quickly, that are generally maintained over time, creating a trauma-informed environment for clients. Future directions include assessing client outcomes as they may relate to changes in provider attitudes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Predicting Teacher Participation in a Classroom-Based, Integrated Preventive Intervention for Preschoolers.

Preschools provide a promising setting in which to conduct preventive interventions for childhood problems, but classroom programs can only be effective if teachers are willing and able to implement them. This study is one of the first to investigate predictors of the frequency of teacher participation in a classroom-based, randomized controlled trial of an integrated prevention program for preschoolers. The intervention was designed to promote school readiness with an integrated social and academic program, to be implemented by teachers with the support of classroom consultants. The current study is part of a larger project conducted with Head Start and community child care centers that serve primarily economically disadvantaged families; 49 teachers from 30 centers participated in this study. Overall, teachers conducted approximately 70% of the program activities. Participation decreased significantly over time from the first to the final week of the intervention, and also decreased within each week of the intervention, from the first to the final weekly activity. Teachers working at community child care centers implemented more intervention activities than did Head Start teachers. Teacher concerns about the intervention, assessed prior to training, predicted less participation. In addition, teachers' participation was positively related to their perception that their centers and directors were supportive, collegial, efficient, and fair, as well as their job satisfaction and commitment. Teacher experience, education, ethnicity, and self-efficacy were not significantly related to participation. In multi-level models that considered center as a level of analysis, substantial variance was accounted for by centers, pointing to the importance of considering center-level predictors in future research.

Evaluating foundational professional development training for trauma-informed approaches in schools.

Trauma-informed schools reflect a national movement toward implementing organizational practices and systems-change strategies that support trauma-exposed individuals. Although frameworks for trauma-informed schools delineate key features for navigating implementation processes, methods of installing these features in schools require additional study. Although foundational professional development (FPD) training is often utilized to prepare schools for implementing trauma-informed approaches, few researchers have examined whether such training influences factors known to promote implementation success: staff knowledge of and perceptions of acceptability for these approaches. The current study utilized a pre-post design to evaluate a 2-day FPD training as a tool for enhancing teacher knowledge of trauma-informed approaches prior to implementation. The study also examined whether gains in knowledge following the training were associated with teacher perceptions of acceptability of trauma-informed approaches and whether perceived alignment of trauma-informed approaches with existing school norms and practices, or system fit, moderated that relationship. Participants included 183 teachers from six schools who completed the training. Knowledge was assessed at pre- and posttraining, and perceptions of acceptability and system fit were assessed at posttraining. Results indicated significant knowledge growth following the training. Among teachers who perceived better system fit, knowledge growth was associated with increased acceptability for trauma-informed approaches. However, among teachers perceiving less system fit, knowledge growth was associated with decreased acceptability. Implications for the installation and implementation of trauma-informed approaches in schools are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The implementation and effect of trauma-informed care within residential youth services in rural Canada: A mixed methods case study.

OBJECTIVE: The prevalence and associated risks of trauma have led youth-serving institutions to adopt trauma-informed care (TIC). A limited research base has linked TIC with improved outcomes. Associations between TIC and vicarious traumatization (VT) are even less commonly studied. The purpose of this case study is to evaluate the implementation and effect of TIC within 1 residential youth services division in rural Canada using the curriculum-based Risking Connection (RC; Saakvitne et al., 2001) and Restorative Approach (RA; Wilcox, 2012) trauma training programs, with a focus on VT. METHOD: We used an explanatory sequential mixed methods design and a participatory action research approach to evaluate the implementation and effect of RC and RA. Study 1, the quantitative program evaluation, used a prepost design to evaluate the effect of RC and RA on staff. Study 2, the qualitative study, used participant observations and interviews to develop a deeper understanding the quantitative findings. RESULTS: This study replicated previous findings that RC improves attitudes favorable to TIC but found that staff experience of VT increased after TIC training. Qualitative findings suggested that the division was successfully implementing TIC and that increased awareness and discussion of VT were potentially responsible for increases in VT scores. CONCLUSIONS: This case study documents improvements in staff attitudes favorable to TIC post-RC and RA and presents an in-depth analysis of TIC implementation. The study also highlights the complicated relationship between TIC implementation and staff experience of VT. Finally, this study provides a blueprint for conducting program evaluations of TIC. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A Pilot Study Examining the Effectiveness of the PEERS Program on Social Skills and Anxiety in Adolescents with Autism Spectrum Disorder.

The Program for the Evaluation of the Enrichment of Relational Skills (PEERS), a social skills intervention for high functioning adolescents with autism spectrum disorder (ASD), has been proven efficacious in randomized control trials. However, the effectiveness of the PEERS program in community settings has not been studied. The present small-scale pilot study examined the effectiveness of the PEERS program in a community setting. Five adolescents and their caregivers participated in the PEERS intervention. Results indicated that the adolescents showed significant improvement in their social engagement, social cognition, social communication, social motivation, and knowledge of PEERS skills and concepts from pre- to post-intervention. Furthermore, adolescents showed significant reductions in their internalizing and autistic symptoms from pre- to post-intervention. The findings from this small-scale pilot study support the effectiveness of the PEERS program in community-based settings.

Identifying autism in a brief observation.

BACKGROUND: Pediatricians, neurologists, and geneticists are important sources for autism surveillance, screening, and referrals, but practical time constraints limit the clinical utility of behavioral observations. We analyzed behaviors under favorable conditions (ie, video of autism evaluations reviewed by experts) to determine what is optimally observable within 10-minute samples, asked for referral impressions, and compared these to formal screening and developmental testing results. METHODS: Participants (n = 42, aged 15 to 33 months) were typically developing controls and children who screened positive during universal autism screening within a large community pediatric practice. Diagnostic evaluations were performed after screening to determine group status (autism, language delay, or typical). Licensed psychologists with toddler and autism expertise, unaware of diagnostic status, analyzed two 10-minute video samples of participants' autism evaluations, measuring 5 behaviors: Responding, Initiating, Vocalizing, Play, and Response to Name. Raters were asked for autism referral impressions based solely on individual 10-minute observations. RESULTS: Children who had autism showed more typical behavior (89% of the time) than atypical behavior (11%) overall. Expert raters missed 39% of cases in the autism group as needing autism referrals based on brief but highly focused observations. Significant differences in cognitive and adaptive development existed among groups, with receptive language skills differentiating the 3 groups. CONCLUSIONS: Brief clinical observations may not provide enough information about atypical behaviors to reliably detect autism risk. High prevalence of typical behaviors in brief samples may distort clinical impressions of atypical behaviors. Formal screening tools and general developmental testing provide critical data for accurate referrals.