Programmatic Costs of Project ImPACT for Children with Autism: A Time-Driven Activity Based Costing Study.

Programmatic cost assessment of clinical interventions can inform future dissemination and implementation efforts. We conducted a randomized trial of Project ImPACT (Improving Parents As Communication Teachers) in which community early intervention (EI) providers coached caregivers in techniques to improve young children's social communication skills. We estimated implementation and intervention costs while demonstrating an application of Time-Driven Activity-Based Costing (TDABC). We defined Project ImPACT implementation and intervention as processes that can be broken down successively into a set of procedures. We created process maps for both implementation and intervention delivery. We determined resource use and costs, per unit procedure in the first year of the program, from a payer perspective. We estimated total implementation cost per clinician and per site, intervention cost per child, and provided estimates of total hours spent and associated costs for implementation strategies, intervention activities and their detailed procedures. Total implementation cost was $43,509 per clinic and $14,503 per clinician. Clinician time (60%) and coach time (12%) were the most expensive personnel resources. Implementation coordination and monitoring (47%), ongoing consultation (26%) and clinician training (19%) comprised most of the implementation cost, followed by fidelity assessment (7%), and stakeholder engagement (1%). Per-child intervention costs were $2619 and $9650, respectively, at a dose of one hour per week and four hours per week Project ImPACT. Clinician and clinic leader time accounted for 98% of per child intervention costs. Highest cost intervention activity was ImPACT delivery to parents (89%) followed by assessment for child's ImPACT eligibility (10%). The findings can be used to inform funding and policy decision-making to enhance early intervention options for young children with autism. Uncompensated time costs of clinicians are large which raises practical and ethical concerns and should be considered in planning of implementation initiatives. In program budgeting, decisionmakers should anticipate resource needs for coordination and monitoring activities. TDABC may encourage researchers to assess costs more systematically, relying on process mapping and gathering prospective data on resource use and costs concurrently with their collection of other trial data.

Self-Directed Telehealth Parent-Mediated Intervention for Children With Autism Spectrum Disorder: Examination of the Potential Reach and Utilization in Community Settings.

BACKGROUND: There is a significant need for strategies to increase access to evidence-based interventions for children with autism spectrum disorder (ASD). One novel approach is to train parents to use evidence-based interventions for their child with ASD via telehealth. Pilot work examining the efficacy of one such program, ImPACT Online, demonstrated a high rate of parent program engagement, low attrition, and associated gains in parent learning and child social communication. OBJECTIVE: The objective of this study was to conduct an open trial of ImPACT Online to better understand its dissemination potential. METHODS: We examined the reach and representativeness of families who registered (n=36) compared to families who were referred (n=139) to the open trial for one referral site. We then compared the demographics of all families who enrolled in the open trial (n=112) to families who enrolled in one of two controlled trials of the same program (n=50). We also examined metrics of program engagement for the open and controlled trials, the relationship between program engagement and changes in parents' intervention knowledge, and program evaluation for the participants in the open trial. RESULTS: In total, 25.8% (36/139) of the parents who were given information about the program at their child's diagnostic feedback session registered with the program. The parents who enrolled in the open (OT) and controlled trials (CT), respectively, were similar in gender (OT: 84.8% (95/112); CT: 88% (44/50), female), marital status (OT: 80.4% (90/112) ; CT: 69.6% (32/46), married), education (OT: 58.0% (65/112); CT: 54.0% (27/50), college degree or higher), and employment status (OT: 58.0% (65/112); CT: 65.3% (32/49), employed outside the home). The child participants were similar in terms of gender (OT: 83.0% (93/112); CT: 76.0% (38/50), male) and race and ethnicity (OT: 38.4% (43/112); CT: 24.0% (12/50), minority). However, the mean chronological age of the child participants in the open trial group was significantly higher (Mean=60.0 months) than in the controlled trial group (Mean=43.0 months), with t160=5.22, P<.001. Parents in the open trial engaged with the program at a significantly lower rate than the controlled trial, F3,81=21.14, P<.001. Program engagement was significantly associated with gains in parent intervention knowledge across both the groups, beta=.41, t=2.43, P=.02. Participants in the open access trial evaluated the program highly, but several barriers were noted. CONCLUSIONS: These data suggest that additional strategies may need to be developed to support families in using telehealth-based parent-mediated intervention in community settings.

Using Community Partnerships to Better Understand the Barriers to Using an Evidence-Based, Parent-Mediated Intervention for Autism Spectrum Disorder in a Medicaid System.

Service use disparities have been noted to impede under-resourced families' ability to access high-quality services for their child with autism spectrum disorder (ASD). These disparities are particularly relevant for parent-mediated interventions and may suggest a lack of fit between these interventions and the needs of under-resourced community settings. This study used Roger's Diffusion of Innovations theory to guide community partnerships aimed at understanding the perceived compatibility, complexity, and relative advantage of using an evidence-based, parent-mediated intervention (Project ImPACT) within a Medicaid system. Three focus groups were conducted with 16 Medicaid-eligible parents, and three focus groups were conducted with 16 ASD providers operating within a Medicaid system. Across all groups, parents and providers reported general interest in using Project ImPACT. However, primary themes emerged regarding the need to (a) reduce the complexity of written materials; (b) allow for a more flexible program delivery; (c) ensure a strong parent-therapist alliance; (d) involve the extended family; and (e) help families practice the intervention within their preexisting routines. Results are discussed as they relate to the design and fit of evidence-based, parent-mediated interventions for under-resourced community settings.

Parent Engagement With a Telehealth-Based Parent-Mediated Intervention Program for Children With Autism Spectrum Disorders: Predictors of Program Use and Parent Outcomes.

BACKGROUND: There has been growing interest in using telehealth to increase access to parent-mediated interventions for children with ASD. However, little is known about how parents engage with such programs. OBJECTIVE: This paper presents program engagement data from a pilot study comparing self-directed and therapist-assisted versions of a novel telehealth-based parent-mediated intervention for young children with autism spectrum disorders (ASD). METHODS: Parents of young children with ASD were randomly assigned to receive a self-directed or therapist-assisted version of ImPACT Online. Parent engagement and satisfaction with the different components of the program website were examined using the program's automated data collection and a post-treatment evaluation survey. We examined the relationship between program engagement and changes in parent knowledge and implementation and participant characteristics associated with program engagement. RESULTS: Of the 27 parent participants, the majority were female (26/27, 96%), married (22/27, 81%), with a college degree or higher (18/27, 66%), and less than half were employed outside of the home (10/27, 37%). The mean chronological age of the child participants was 43.26 months, and the majority were male (19/27, 70%) and white (21/27, 78%). Most of the families (19/27, 70%) resided in a rural or medically underserved area. Parents logged into the website an average of 46.85 times, spent an average of 964.70 minutes on the site, and completed an average of 90.17% of the lesson learning activities. Participants in the therapist-assisted group were more likely to engage with the website than those in the self-directed group: F2,24=17.65, P<.001. In total, 85% of participants completed the program, with a significantly greater completion rate in the therapist-assisted group (N=27): χ(2) 1=5.06, P=.03. Lesson learning activities were visited significantly more often than the supplemental activities (all Ps<.05). Multiple regression controlling for pretreatment performance indicated that program completion (beta=.51, P=.02) predicted post-treatment intervention knowledge, and program completion (beta=.43, P=.03) and group assignment (beta=-.37, P=.045) predicted post-treatment intervention fidelity. Partial correlations indicated that parent depressive symptoms at pretreatment were negatively associated with program completion (r=-.40, P=.04), but other key parent and child demographic factors were not. Post-treatment measures of website usability (r=.65, P<.001), treatment acceptability (r=.58, P=.002), and overall satisfaction (r=.58, P=.002) were all related to program completion. CONCLUSIONS: Parent engagement and satisfaction with ImPACT Online was high for both self-directed and therapist-assisted versions of the program, although therapist assistance increased engagement. Program completion was associated with parent outcomes, providing support for the role of the website in parent learning. This program has the potential to increase access to parent-mediated intervention for families of children with ASD.

Using virtual multiteam systems to conduct a multisite randomized clinical trial in the part C early intervention system: Benefits, challenges, and lessons learned.

BACKGROUND/AIMS: COVID-19 necessitated a shift to virtual data collection for many research projects, providing the opportunity for novel approaches to carrying out multi-site clinical trials. Virtual multiteam systems (VMTS) are a type of team structure in which multiple geographically dispersed teams collaborate using technology-mediated communication. The article presents a case study of our use of VMTS, in response to COVID-19, to carry out a multisite randomized hybrid effectiveness-implementation trial of a caregiver-implemented intervention. METHODS: We describe how we modified our team structure from predominantly site-specific, co-located teams to predominantly cross-site, virtual teams. We then present examples of how we have conducted the two primary data collection activities virtually. To demonstrate the feasibility of this approach, we present participant demographic information, the percent of cross-site data collection activities, and fidelity data. RESULTS: In the first 20 months of data collection, we have enrolled 108 EI providers and 132 families, with 17% and 9% attrition respectively. The family sample is highly diverse in terms of race/ethnicity, parent education, and household income. The majority of provider training activities and roughly 50% of family assessment activities have been conducted cross-site. Fidelity is high, with no differences across site. CONCLUSIONS: Our data illustrate the feasibility of using virtual teams, training, and assessment in a multisite clinical trial in the Part C system. We discuss the strengths and challenges of this approach, as well as lessons learned to facilitate the planning of future multisite randomized clinical trials which may benefit from this approach. CLINICAL TRIALS: NCT05114538.

Applying a User-Centered Design Framework to Develop a Remote Research Assessment Protocol for a Randomized Clinical Trial for Toddlers with Early Autism Characteristics.

COVID-19 required many research teams to shift from in-person to remote assessments, which posed both procedural and theoretical challenges. While research has explored the utility of remote assessments for autism diagnosis from the perspective of families and clinicians, less is known about their application in clinical trials. This paper describes the development of a remote research assessment protocol for a randomized clinical trial focusing on the implementation of reciprocal imitation teaching (RIT) with toddlers in Part C early intervention. This project spans two phases. For Phase 1, our team developed and documented a series of steps utilizing user-centered design (UCD) strategies (e.g., recruiting potential users, creating a prototype, engaging in iterative development) for the purpose of redesigning an assessment protocol for a remote environment. For Phase 2, we examined preliminary outcomes of the redesign process. Primary end users (assessors) rated post-redesign usability and acceptability, while acceptability was examined using attrition data from secondary end users (family participants). Preliminary fidelity of implementation was also examined. The iterative redesign process allowed the research team to refine aspects of the assessment that ultimately led to promising preliminary ratings of usability, acceptability, and feasibility, as well as high fidelity. Preliminary data suggest that the redesigned assessment appears to be an acceptable, feasible, and usable tool for autism clinical trial research and that assessors can use it with fidelity. Further research is needed to examine the reliability and validity of the assessment, as well as implementation characteristics on a larger scale.

Factors that influence clinical decisions about offering parent coaching for autistic youth served within the Medicaid system.

Background: Parent coaching is an evidence-based practice for young autistic children, but it is underutilized in lower-resourced community settings like the Medicaid system (Straiton et al., 2021b). Clinicians often struggle to implement parent coaching with low-income and marginalized families (Tomczuk et al., 2022), but little is known about which factors influence clinician decision making processes about providing parent coaching to this population. Methods: This qualitative analysis used the framework method and thematic analysis. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework (Aarons et al., 2011) to identify factors in the clinical decision-making process that community providers use when offering parent coaching to families of Medicaid-enrolled autistic children. Interviews with 13 providers and a focus group with 13 providers were analyzed. Results: The following themes emerged: 1) Policies drive provider task priorities and affect competing demands; 2) Providers are more likely to use parent coaching when agency leaders monitor parent coaching benchmarks, though this is rarely done; 3) Logistical factors like scheduling and treatment location affect perceived feasibility of using parent coaching; 4) Previous experience or coursework in parent coaching and/or family systems supports the quality of parent coaching implementation; 5) Provider perceptions of "parent readiness" are initially indicated by overt expressions of parent interest. Conclusions: In the absence of outer-context and inner-context policies, providers have more decision-making power to offer parent coaching based on their own judgements and preferences, which may result in fewer families being offered parent coaching and increased bias related to which families are offered this service. State-, agency-, and clinician-level recommendations are provided for increasing equitable provision of this evidence-based practice for autism.

Balancing Fidelity and Flexibility: Usual Care for Young Children With an Increased Likelihood of Having Autism Spectrum Disorder Within an Early Intervention System.

Naturalistic developmental behavioral interventions (NDBIs) are evidence-based interventions for young children with autism spectrum disorder. There has been growing interest in implementing manualized NDBIs within the early intervention (EI) system without a clear understanding of how these programs and the broader strategies encompassed within them are already used by EI providers. This study examined the use of manualized NDBI programs and broader NDBI strategies within an EI system and factors that impacted their use. Eighty-eight EI providers completed a measure of NDBI program and strategy use. Thirty-three providers participated in a supplemental focus group or interview. Overall, providers described using broader NDBI strategies and the need to adapt manualized NDBI programs. Provider-, intervention-, and organization-level factors impacted their use of NDBI programs and strategies.

A mixed-methods examination of clinicians' perceived barriers to telehealth delivered applied behavior analysis.

Following the COVID-19 pandemic, clinicians relied on telehealth to ensure continuity of essential healthcare services, such as Applied Behavior Analysis (ABA). Identifying barriers and examining them in the context of other implementation outcomes is important to support appropriate adaptations and sustainability of telehealth-delivered ABA services. Convergent mixed methods design was utilized to identify barriers experienced by ABA clinicians (N = 388) when delivering ABA services over telehealth to autistic children and their families following the first six months of the COVID-19 pandemic. Additionally, barriers were examined in relation to telehealth implementation outcomes and intentions for continued adoption. Findings reveal that clinicians rated providing direct services (M = 3.52, SD = 1.14) as more difficult than conducting assessments (M = 3.29, SD = 1.06), and both as more difficult than providing parent-mediated interventions [(M = 2.47, SD = 1.11), F(2, 381) = 162.26, p < 0.001]. A principal components analysis indicated a 3-factor solution of barriers related to: (1) technology (α = 0.82), (2) administrative tasks (α = 0.88), and (3) client characteristics (α = 0.88). The most frequently endorsed barriers were related to client characteristics, including increased difficulty providing telehealth services to children who elope (M = 4.37, SD = 0.81), children who exhibit challenging behaviors (M = 4.31; SD = 0.83), and children who are in the preverbal stage or use nonverbal language to communicate (M = 4.07; SD = 1.00). Fewer barriers related to client characteristics uniquely predicted implementation variables including acceptability, appropriateness, and feasibility. Thematic analysis revealed challenges related to technology, caregiver involvement, child engagement, implementation of intervention strategies over telehealth, and administrative or logistical barriers. These findings highlight the need for targeted strategies that facilitate telehealth use to address specific client needs and support the implementation of telehealth services in usual care settings.

Relative Efficacy of Self-directed and Therapist-assisted Telehealth Models of a Parent-mediated Intervention for Autism: Examining Effects on Parent Intervention Fidelity, Well-being, and Program Engagement.

PURPOSE: Although there is growing interest in telehealth to deliver parent-mediated intervention for autistic children, empirical evaluations are limited, and little is known regarding the relative benefits of self-directed and therapist-assisted telehealth interventions. This study examined the effect of self-directed and therapist-assisted ImPACT Online on parent learning and well-being, moderators of treatment, and predictors of program engagement. METHOD: Sixty-four young autistic children and their primary caregiver participated. Children were matched on age and developmental quotient and randomly assigned to a therapist-assisted, self-directed, or resource support control group. Participants were assessed at intake, after 6 months (post), and at a 3-month follow-up. RESULTS: There was a significant treatment effect for parent learning for the therapist-assisted but not self-directed program; when analysis was limited to parents who completed the program, treatment effects were observed for both groups. There were no treatment effects for parent self-efficacy or parenting stress; however, there was an effect on parents' perception of their child's positive impact. Parenting stress did not moderate the effect of group on parent outcomes. Parent age, program satisfaction, and therapist assistance were all significant predictors of parent program engagement. CONCLUSION: This study supports the efficacy of therapist-assisted telehealth parent-mediated intervention for teaching parents intervention strategies to support their child's social communication and improving their perceptions of their child's positive impact, and suggests that self-directed programs may be beneficial for parents who fully engage with the program.

Brief Report: Response to Joint Attention and Object Imitation as Predictors of Expressive and Receptive Language Growth Rate in Young Children on the Autism Spectrum.

Joint attention and imitation are thought to facilitate a developmental cascade of language and social communication skills. Delays in developing these skills may affect the quality of children's social interactions and subsequent language development. We examined how responding to joint attention and object imitation skills predicted rate of expressive and receptive communication growth rate in a heterogeneous sample of autistic children. Children's baseline skills in responding to joint attention uniquely predicted expressive, but not receptive, language growth rate over time, while object imitation did not significantly predict language growth rate over and above joint attention skills. Future research should examine the potential moderating roles of child age and developmental level in explaining associations between joint attention and object imitation and later language development.

Revisiting the simplification of adult language input in the context of naturalistic developmental behavioral interventions: A commentary.

Naturalistic developmental behavioral interventions (NDBI) are an evidence-based class of early interventions for improving language and social communication skills in autistic children. However, relatively little is known about how individual elements of NDBI support child development. This commentary focuses on one common element across NDBI models: the simplification of adult language input. Advances in developmental science focusing on the length and complexity of adult spoken utterances suggests that natural, grammatical utterances facilitate comprehension and expressive language development in autistic and nonautistic children. Yet, NDBI tend to recommend shorter and simpler adult utterances. We close by describing directions for future research which would inform recommendations around adult language input in NDBI to optimally support child language and communication development.

Characterizing Available Tools for Synchronous Virtual Assessment of Toddlers with Suspected Autism Spectrum Disorder: A Brief Report.

The COVID-19 pandemic, and associated social distancing mandates, has placed significant limitations on in-person health services, requiring creative solutions for supporting clinicians engaged in the diagnosis of autism spectrum disorder (ASD). This report describes the five virtual instruments available at the time of manuscript development for use by experienced clinicians making diagnostic determinations of ASD for toddlers across the 12- to 36-months age range. We focus on synchronous virtual assessments in which clinicians guide the child's caregiver through a range of assessment activities and observe spontaneous and elicited behaviors. Assessments are compared on dimensions of targeted behavioral domains, specific activities and presses employed, scoring approaches, and other key logistical considerations to guide instrument selection for use in varied clinical and research contexts.

A method for defining the CORE of a psychosocial intervention to guide adaptation in practice: Reciprocal imitation teaching as a case example.

LAY ABSTRACT: Interventions that support social communication include several "components," or parts (e.g. strategies for working with children and families, targeting specific skills). Some of these components may be essential for the intervention to work, while others may be recommended or viewed as helpful but not necessary for the intervention to work. "Recommended" components are often described as "adaptable" because they can be changed to improve fit in different settings where interventions are offered or with different individuals. We need to understand which parts of an intervention are essential (and which are adaptable) when translating interventions from research to community settings, but it is challenging to do this before studying an intervention in the community. This article presents the CORE (COmponents & Rationales for Effectiveness) Fidelity Method-a new method for defining the essential components of evidence-based interventions-and applies it to a case example of Reciprocal Imitation Teaching, an intervention that parents are taught to deliver with their young children with social communication delays. The CORE Fidelity Method involves three steps: (1) gathering information from multiple sources; (2) integrating information from previous research and theory; and (3) drafting a CORE model for ongoing use. The benefits of using the CORE Fidelity Method may include: (1) improving consistency in intervention and research materials to help all providers emphasize the most important skills or strategies; (2) clarifying which parts of the intervention can be adapted; and (3) supporting future research that evaluates which intervention components work and how they work.

Factors related to parental therapeutic self-efficacy in a parent-mediated intervention for children with autism spectrum disorder: A mixed methods study.

LAY ABSTRACT: Parental self-efficacy refers to parents' beliefs in their ability to successfully parent their child. Parental self-efficacy plays an important role in family outcomes when a child has autism spectrum disorder. It is important to consider therapeutic self-efficacy, one's feelings of self-efficacy regarding their implementation of an intervention, within parent-mediated interventions. The goal of this mixed methods study was to better understand factors that relate to parents' therapeutic self-efficacy when using a telehealth-based parent-mediated intervention. Participants were 51 parents of children with autism spectrum disorder between 17 and 83 months old. Parents had generally high therapeutic self-efficacy, and global parental self-efficacy was significantly related therapeutic self-efficacy. Parents' written reflections revealed four themes that related to their therapeutic self-efficacy: the importance of a good fit between the child's skills and the intervention, the importance of a good fit between the parent's interaction style and the intervention, environmental factors support intervention use, and the importance of the child's response to the intervention. Several themes differed for parents with higher and lower therapeutic self-efficacy. Findings suggest that global parental self-efficacy plays an important role in parental therapeutic self-efficacy in parent-mediated interventions. To support parents in learning, coaches should ask about the child's skills, parent's interaction style, environmental challenges, and child's response.

Parent Training for Youth with Autism Served in Community Settings: A Mixed-Methods Investigation Within a Community Mental Health System.

Parent training programs focus on parent knowledge and/or skill development regarding strategies to improve child outcomes. Parent training programs are considered evidenced-based treatments for autism spectrum disorder (ASD). Yet little is known about parent training use for youth with ASD served in community settings. This mixed methods project examined parent training for Medicaid-enrolled youth with ASD under age 21. Data were obtained from Medicaid claims for 879 youth and surveys from 97 applied behavior analysis (ABA) providers. Open-ended survey items were analyzed with content analysis. Results demonstrated that the frequency of parent training was low and providers' conceptualization of parent training was inconsistent with evidence-based models. Providers are largely unaware of evidence-based components (i.e., modeling, caregiver practice with feedback) and use them infrequently. Implications for increasing parent training in community settings are discussed.

Using qualitative content analysis to understand the active ingredients of a parent-mediated naturalistic developmental behavioral intervention.

LAY ABSTRACT: Although naturalistic developmental behavioral interventions are supported by research for supporting the development of children on the autism spectrum, how they work is not well understood. This study reviewed parent reflection comments in a systematic way to better how one such treatment worked, when delivered by caregivers. Caregivers completed weekly written reflection responses as they learned how to use the treatment techniques. We studied these responses to understand caregiver perspectives on how their children responded to the techniques. The responses were then compared to a theory of how the treatment works. Many responses were consistent with the treatment theory; however, others were not. We found that individual techniques were associated with different child responses, suggesting that general measures of social communication may not measure these specific short-term changes. Our findings point to specific behaviors that may be useful to measure in future research, or useful as indicators of treatment response in clinical practice settings. Overall, qualitative methods may be useful for understanding complex treatment processes.

A mixed methods exploration of community providers' perceived barriers and facilitators to the use of parent training with Medicaid-enrolled clients with autism.

LAY ABSTRACT: Using quantitative data from an online survey and qualitative data from follow-up interviews with applied behavior analysis providers, researchers examined barriers and facilitators to providing parent training to Medicaid-enrolled youth with autism spectrum disorder. Barriers and facilitators were identified at the family-, provider-, and organization-levels. Family-level barriers were significantly related to less frequent parent training use and poorer quality of use. Two recommendations are provided to increase the use of parent training in low-resourced community settings: (1) provide professional training opportunities to providers about best practices in parent training and (2) increase agency support for parent training, particularly in reducing logistical barriers.

Age differences in broader autism phenotype traits from young adulthood to older adulthood.

Much of past research has been dedicated to refining the operationalization and correlates of the broader autism phenotype (BAP) and less on how the BAP differs by socio-demographic characteristics, like age-particularly after midlife. This gap is important because other nonclinical trait-like characteristics (e.g., personality) have shown considerable age differences, leading to work assessing the malleability of psychological characteristics and improving outcomes for individuals and their significant others. In the current study, we examined cross-sectional age differences in the BAP in a large sample of adults ranging in age from 18 to 85. We recruited a sample of 2966 adults ranging in age from 18 to 85 (Mage = 36.53, SD = 12.61; 58.9% Female; 1.1% with an ASD diagnosis) recruited from an online survey service. We found that total BAP scores were higher in younger adults and lower among older adults. These differences were particularly true for pragmatic language difficulties, with this component of the BAP showing the most dramatic age differences. Aloofness showed similar negative associations with age, albeit much smaller. Rigidity was not significantly associated with age. The results are consistent with other research showing an abatement of symptoms among individuals with autism spectrum disorders (ASDs) across early life and theories predicting changes in other psychological characteristics (e.g., personality). The results are discussed in the context of the malleability of ASD and BAP traits across life, the clinical implications of these changes, and the origins and consequences for lifespan differences in BAP. LAY SUMMARY: Little is known about how subclinical autistic-like traits among middle-aged and older adults compare to younger adults. We found that these subclinical traits were highest in young adults and lowest in older adults. Knowing how these traits differ by age can provide researchers and clinicians with a sense of how much these traits might change across life, if the traits might be sensitive to interventions, and when in development it might be best to intervene.

Prenatal phthalate exposures and autism spectrum disorder symptoms in low-risk children.

BACKGROUND: Prenatal exposure to environmental chemicals has been associated with Autism Spectrum Disorder (ASD) symptoms in some, but not all, studies, but most research has not accounted for other childhood behavior problems. OBJECTIVES: To evaluate the specific associations of prenatal phthalate exposures with ASD symptoms in children (ages 3-6) accounting for other behavior problems, and to assess sex differences in these associations. METHODS: We measured phthalate metabolites in prenatal urine samples. Mothers completed the Social Responsiveness Scale-2nd edition (SRS-2) to assess child ASD symptoms and the Child Behavior Checklist (CBCL) to assess general behavior problems. We assessed associations of the sum of di-(2-ethylhexyl) phthalate metabolites, monobutyl phthalate, mono-isobutyl phthalate, and monoethyl phthalate (mEP) with ASD symptoms, adjusting for other behavior problems, using linear regression models (n=77). RESULTS: Most associations were null, and the sample size limited power to detect associations, particularly in the stratified analyses. After adjusting for internalizing and externalizing problems from the CBCL, ASD symptoms increased for each doubling of prenatal mEP concentration among boys only. CONCLUSIONS: Further investigation of maternal prenatal urinary phthalate metabolite concentrations and ASD symptoms while adjusting for other behavioral problems is warranted.