Community testing practices for autism within the autism and developmental disabilities monitoring network.

BACKGROUND: No data exist at the population level on what tests are used to aid in the diagnosis of autism spectrum disorder in community practice. OBJECTIVES: To describe autism spectrum disorder testing practices to inform autism spectrum disorder identification efforts. METHODS: Data are from the Autism and Developmental Disabilities Monitoring Network, a multi-site surveillance system reporting prevalence estimates and characteristics of 8-year-old children with autism spectrum disorder. Percentages of children with autism spectrum disorder who received any autism spectrum disorder test or a 'gold standard' test were calculated by site, sex, race, median household income, and intellectual ability status. Risk ratios were calculated to compare group differences. RESULTS: Of 5058 8-year-old children with autism spectrum disorder across 11 sites, 3236 (64.0%) had a record of any autism spectrum disorder test and 2136 (42.2%) had a 'gold standard' ADOS or ADI-R test. Overall, 115 children (2.3%) had both the ADOS and ADI-R in their records. Differences persisted across race, median household income, and intellectual ability status. Asian/Pacific Islander children had the highest percent receiving any ASD test (71.8%; other groups range: 57.4-66.0%) and White children had the highest percent receiving 'gold standard' tests (46.4%; other groups range: 35.6-43.2%). Children in low-income neighbourhoods had a lower percent of any test (62.5%) and 'gold standard' tests (39.4%) compared to medium (70.2% and 47.5%, respectively) and high (69.6% and 46.8%, respectively) income neighbourhoods. Children with intellectual disability had a lower percent of any ASD test (81.7%) and 'gold standard' tests (52.6%) compared to children without intellectual disability (84.0% and 57.6%, respectively). CONCLUSIONS: Autism spectrum disorder testing practices vary widely by site and differ by race and presence of co-occurring intellectual disability, suggesting opportunities to standardise and/or improve autism spectrum disorder identification practices.

Leveraging Motivational Interviewing to Coach Teachers in the Implementation of Preventive Evidence-Based Practices: A Sequential Analysis of the Motivational Interviewing Process.

Though emerging research supports the effectiveness of school-based coaching models utilizing motivational interviewing (MI), an examination of the specific drivers behind these effects is notably lacking in the prevention field. This study leveraged sequential analysis to examine how teachers' verbalization of change talk (i.e., language in support of change) and sustain talk (i.e., language in support of maintaining the status quo) was influenced by coaches' use of MI-consistent (i.e., collaborative language supportive of change) and MI-inconsistent (e.g., confrontational, directive) language, respectively. We also examined whether teacher and coach factors were related to coach-teacher language dynamics. Data were collected from 87 teachers in 16 elementary and middle schools randomized in a trial to the Double Check preventive intervention (see Bradshaw et al., 2018). Audio-recorded coaching feedback sessions were coded using an adapted version of the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE). Sequential analyses indicated that MI-consistent and change talk were significantly more likely than chance to occur consecutively. Teachers' sustain talk was also more likely to occur sequentially with coach use of MI-consistent language and teacher change talk; the latter suggests teacher ambivalence. Coaches rarely used MI-inconsistent language, and its occurrence was only associated with more MI-inconsistent language. Regression analyses indicated that teacher age, efficacy, burnout, classroom organization, and some design features (i.e., cohort, coach, coach-teacher racial match) were associated with different coach-teacher language dynamics. This novel school-based study illustrates how coaching MI evoked teacher change talk related to use of evidence-based programs.

Can Policy Promote Adoption or Outcomes of Evidence-based Prevention Programming?: a Case Illustration of Positive Behavioral Interventions and Supports.

This study examined the impact of a state policy requiring that any school with a habitual truancy rate of 8% or higher to be trained in Tier 1 school-wide Positive Behavioral Interventions and Supports (SW-PBIS). A regression discontinuity (RD) design was used to examine how the schools' mandate status related to SW-PBIS training as well as student suspensions, truancy, and achievement in 410 public middle and high schools, of which 261 were affected by the mandate. We further examined the growth trajectories (i.e., improvement) of implementation fidelity over time using growth mixture modeling (GMM). Contrary to the intent of the policy to improve student outcomes, the RD results suggested that the mandate did not significantly impact reading and math achievement, truancy rates, or SW-PBIS training in 2010-2011 through 2013-2014. Mandated schools had higher suspension rates in 2010-2011 through 2013-2014 than the non-mandated schools; however, these differences in the suspension rates appear to have persisted from years prior to the mandate. Descriptive analyses suggested that mandated schools had statistically significantly higher rates of training, and the GMM analyses on the fidelity data indicated that mandated schools were significantly more likely to be in an improving implementation growth trajectory over time. Taken together, results suggested that the policy showed some promise for improving SW-PBIS training and fidelity over time, but it had little to no impact on student outcomes.

A Cost Analysis of Traditional Professional Development and Coaching Structures in Schools.

Current achievement data indicate a public health concern, whereby the majority of students are not proficient in reading or math. Teacher professional development is frequently the preventive mechanism schools utilize to improve instruction, student achievement, and subsequent long-term economic and health-related outcomes. This study used the ingredients method to examine the costs associated with two common structures of professional development: traditional workshops and coaching. Results suggested that the cost per educator per contact hour ranged from $138.29 to $158.45 for workshops and was $169.43 for coaching, in 2017-2018 US dollars. The distribution of costs indicated that local districts incurred the majority of the costs for traditional workshops (i.e., range of 74.76% to 81.03%), whereas regional providers incurred the majority of the costs for coaching (i.e., 58.75%). Marginal costs, or the costs for one additional participant at one traditional workshop, ranged from $663.64 to $1132.78 and were $441.32 for coaching an additional peer teacher within one school building. Marginal costs increased to $2060.21 when coaching an additional peer teacher in an additional building. Implications for practice and suggestions for future research are discussed.

Informant Discrepancies in Internalizing and Externalizing Symptoms in an At-Risk Sample: The Role of Parenting and School Engagement.

A number of studies have used variable-centered approaches to examine informant discrepancies on children's behavior problems; however, few such studies have used person-centered approaches to explore patterns of informant discrepancies or correlates of discrepancies in informant symptom ratings. The present study addressed these gaps by examining profiles of informant agreement on internalizing and externalizing symptoms and examining whether two important contextual factors, parenting and school engagement, are associated with profile membership. Data from an at-risk, urban sample of youth participants (N= 346, M age = 12.47 ± 0.60 years, 56% male, and 75% Black), their caregivers, and one of their teachers were analyzed in the current study. Youth from 20 schools in a Mid-Atlantic state were screened for elevated levels of aggression and were selected to participate in the Early Adolescent Coping Power study. At baseline, youth, caregivers, and teachers reported on youth's internalizing symptoms and caregivers and teachers reported on youth's externalizing symptoms. Caregivers reported on their parenting; youth reported on their school engagement. Two internalizing symptoms profiles were identified: Low Symptoms Agreement and Youth-Reported High Somatization and Anxiety. Three externalizing symptoms profiles were identified: Low Symptoms Agreement, Teacher-Reported High Externalizing, and Caregiver-Reported High Externalizing. These profiles differed significantly on parenting behaviors and school engagement, shedding light on factors that may underlie informant discrepancies.

Tracking Time and Resources Associated with Systems Change and the Adoption of Evidence-Based Programs: The "Hidden Costs" of School-Based Coaching.

This study leveraged data from a 40-school randomized controlled trial to understand the cost of coaching to support implementation of evidence-based programs (EBPs) through a multi-tiered system of supports for behavior (MTSS-B) model. Coach activity log data were utilized to generate the annual average, per school, costs of coaching of $8198. The cost of school personnel time for coaching was estimated to be $3028. Data on coach-rated administrator buy-in, school MTSS-B engagement, and implementation infrastructure and capacity were also collected and found to be associated with coaching activities. Notably, coaches did not spend significantly different amounts of time in schools using few EBPs relative to more EBPs, indicating some inefficiency in the use of coaches' time. These findings highlight the often-overlooked resources needed to support EBP implementation in schools.

Using Complier Average Causal Effect Estimation to Examine Student Outcomes of the PAX Good Behavior Game When Integrated with the PATHS Curriculum.

A growing body of research has documented a link between variation in implementation dosage and outcomes associated with preventive interventions. Complier Average Causal Effect (CACE; Jo in J Educ Behav Stat 27:385-409, 2002) analysis allows for estimating program impacts in light of variation in implementation. This study reports intent-to-treat (ITT) and CACE findings from a randomized controlled trial (RCT) testing the impacts of the universal PAX Good Behavior Game (PAX GBG) integrated with Promoting Alternative Thinking Strategies (i.e., PATHS to PAX) and PAX GBG only compared to a control. This study used ratings by 318 K-5 teachers of 1526 at-risk children who, at baseline, were rated as displaying the top 33rd percentile of aggressive-disruptive behavior. Leveraging a prior study on these data (Berg et al. in Admin Policy Ment Health Ment Health Serv Res 44:558-571, https://doi.org/10.1007/s10488-016-0738-1 , 2017), CACE was defined as the effect of intervention assignment for compliers, using two compliance cut points (50th and 75th percentile), on posttest ratings of student academic engagement, social competence, peer relations, emotion regulation, hyperactivity, and aggressive-disruptive behavior. The ITT analyses indicated improvements for students in the integrated condition on ratings of social competence compared to the control condition. The CACE analyses also indicated significant effects of the integrated intervention on social competence, as well as academic engagement and emotion regulation for students in high compliance classrooms. These findings illustrate the importance of considering variation in implementation within the context of RCTs.

How do collective student behavior and other classroom contextual factors relate to teachers' implementation of an evidence-based intervention? A multilevel structural equation model.

Building on prior work regarding the potential for peer contagion or deviance training in group delivered interventions (Dishion & Dodge, 2005, 2006; Dodge, Dishion, & Lansford, 2006), we leveraged data from a randomized trial, testing the integration of two preventive interventions (Promoting Alternative THinking Strategies and PAX Good Behavior Game), to explore the extent to which classroom contextual factors served as either a barrier to or a motivator for teachers to implement the evidence-based PAX Good Behavior Game with high frequency or dosage. We included students' baseline levels of behavior, measured with regard to both positive (i.e., engagement and social emotional skills) and negative (i.e., hyperactive and aggressive-disruptive) behaviors. Data were collected from 204 teachers in 18 urban elementary schools. A series of multilevel structural equation models were fit to the data. The analyses indicated that classrooms with higher classroom levels of aggressive behavior, on average, at baseline had teachers with lower implementation dosage (i.e., played fewer games) across the school year. In addition, teachers who reported higher baseline levels of emotional exhaustion, regardless of student behavior, also reported lower implementation dosage. Taken together, the results indicated that negative, but not positive, contextual factors at baseline were related to lower implementation dosage; this, in turn, suggests that negative contextual factors may serve as a barrier, rather than a motivator, of teachers' implementation dosage of classroom-based preventive interventions.

Promoting Teachers' Implementation of Classroom-Based Prevention Programming Through Coaching: The Mediating Role of the Coach-Teacher Relationship.

There is growing awareness of the importance of implementation fidelity and the supports, such as coaching, to optimize it. This study examined how coaching activities (i.e., check-ins, needs assessment, modeling, and technical assistance) related directly and indirectly to implementation dosage and quality of the PAX Good Behavior Game, via a mediating pathway through working relationship. Mediation analyses of 138 teachers revealed direct effects of modeling and working relationship on implementation dosage, whereas needs assessment was associated with greater dosage indirectly, by higher ratings of the working relationship. Understanding how coaching activities promote implementation fidelity elements has implications for improving program effectiveness.

Understanding and Measuring Coach-Teacher Alliance: A Glimpse Inside the 'Black Box'.

Coaching models are increasingly used in schools to enhance fidelity and effectiveness of evidence-based interventions; yet, little is known about the relationship between the coach and teacher (i.e., coach-teacher alliance), which may indirectly enhance teacher and student outcomes through improved implementation quality. There is also limited research on measures of coach-teacher alliance, further hindering the field from understanding the active components for successful coaching. The current study examined the factor structure and psychometric characteristics of a measure of coach-teacher alliance as reported by both teachers and coaches and explored the extent to which teachers and coaches reliably rate their alliance. Data come from a sample of 147 teachers who received implementation support from one of four coaches; both the teacher and the coach completed an alliance questionnaire. Separate confirmatory factor analyses for each informant revealed four factors (relationship, process, investment, and perceived benefits) as well as an additional coach-rated factor (perceived teacher barriers). A series of analyses, including cross-rater correlations, intraclass correlation coefficients, and Kuder-Richardson reliability estimates suggested that teachers and coaches provide reliable, though not redundant, information about the alliance. Implications for future research and the utilization of the parallel coach-teacher alliance measures to increase the effectiveness of coaching are discussed.

How Do School-Based Prevention Programs Impact Teachers? Findings from a Randomized Trial of an Integrated Classroom Management and Social-Emotional Program.

A number of classroom-based interventions have been developed to improve social and behavioral outcomes for students, yet few studies have examined how these programs impact the teachers who are implementing them. Impacts on teachers may affect students and therefore also serve as an important proximal outcome to examine. The current study draws upon data from a school-based randomized controlled trial testing the impact of two prevention programs. In one intervention condition, teachers were trained in the classroom behavior management program, PAX Good Behavior Game (PAX GBG). In a second intervention condition, teachers were trained to use an integrated program, referred to as PATHS to PAX, of the PAX GBG and a social and emotional learning curriculum called Promoting Alternative Thinking Strategies (PATHS©). This study aimed to determine whether both interventions positively impacted teachers, with a particular interest in the teachers' own beliefs and perceptions regarding self-efficacy, burnout, and social-emotional competence. The sample included 350 K-5 teachers across 27 schools (18 schools randomized to intervention, 9 to control). Multilevel latent growth curve analyses indicated that the PATHS to PAX condition generally demonstrated the most benefits to teachers, relative to both the control and PAX GBG conditions. These findings suggest that school-based preventive interventions can have a positive impact on teachers' beliefs and perceptions, particularly when the program includes a social-emotional component. Several possible mechanisms might account for the added benefit to teachers. Additional research is needed to better understand how these programs impact teachers, as well as students.

Examining Contextual Influences on Classroom-Based Implementation of Positive Behavior Support Strategies: Findings from a Randomized Controlled Effectiveness Trial.

Although it is widely recognized that variation in implementation fidelity influences the impact of preventive interventions, little is known about how specific contextual factors may affect the implementation of social and behavioral interventions in classrooms. Theoretical research highlights the importance of multiple contextual influences on implementation, including factors at the classroom and school level (Domitrovich et al., Advances in School Mental Health Promotion, 1, 6-28, 2008). The current study used multi-level modeling to empirically examine the influence of teacher, classroom, and school characteristics on the implementation of classroom-based positive behavior support strategies over the course of 4 years. Data were collected in the context of a 37-school randomized controlled trial examining the effectiveness of school-wide Positive Behavioral Interventions and Supports. Multi-level results identified several school-level contextual factors (e.g., school size, behavioral disruptions) and teacher-level factors (perceptions of school organizational health and grade level taught) associated with variability in the implementation of classroom-based positive behavior supports. Implications for prevention research and practice are discussed.

Individual and School Organizational Factors that Influence Implementation of the PAX Good Behavior Game Intervention.

Evidence-based interventions are being disseminated broadly in schools across the USA, but the implementation levels achieved in community settings vary considerably. The current study examined the extent to which teacher and school factors were associated with implementation dosage and quality of the PAX Good Behavior Game (PAX GBG), a universal classroom-based preventive intervention designed to improve student social-emotional competence and behavior. Specifically, dosage (i.e., number of games and duration of games) across the school year and quality (i.e., how well the game is delivered) of PAX GBG implementation across four time points in a school year were examined. Hierarchical linear modeling was used to examine the association between teacher-level factors (e.g., demographics, self-reports of personal resources, attitudes toward the intervention, and workplace perceptions) and longitudinal implementation data. We also accounted for school-level factors, including demographic characteristics of the students and ratings of the schools' organizational health. Findings indicated that only a few teacher-level factors were significantly related to variation in implementation. Teacher perceptions (e.g., fit with teaching style, emotional exhaustion) were generally related to dosage, whereas demographic factors (e.g., teachers' age) were related to quality. These findings highlight the importance of school contextual and proximal teacher factors on the implementation of classroom-based programs.

Examining potential school contextual influences on gambling among high school youth.

BACKGROUND AND OBJECTIVES: Gambling is an increasing concern among adolescence, yet there has been limited investigation into school-level factors that may increase the risk for gambling. The current study examined the relationship between substance use and gambling, and explored the influence of school context on adolescent gambling. METHODS: Data come from 25,456 students in 58 high schools participating in the Maryland Safe and Supportive Schools Initiative. Youth-reports of socio-demographics, lifetime gambling, and past-month substance use (ie, alcohol, cigarette, marijuana, non-medical prescription drug) were collected. School-level characteristics were student suspension rate, student mobility, percentage of students receiving free/reduce-priced meals, percentage of African American students, urbanicity, gambling prevalence, gambling problem prevalence, and substance use prevalence. Weighted multilevel analyses were conducted. RESULTS: One-third (n = 8,318) reported lifetime gambling, and 10% (n = 2,580) of the full sample, or 31% of the gamblers, experienced gambling problems. Being male and alcohol, marijuana, and non-medical prescription drug use were associated with twice the odds of gambling. Among gamblers, being male, African American, and cigarette, marijuana, and non-medical prescription drug use were associated with higher odds of gambling problems. The school-level factors of suspension rate and percentage of African American had minimal, inverse associations with gambling; however, none were related to gambling problems. CONCLUSIONS: Multilevel results indicated that adolescents that are male and use substances are more likely to gamble and have gambling problems. SCIENTIFIC SIGNIFICANCE: The findings indicate a need for prevention programs targeting risky behaviors to also target gambling as such behaviors often co-occur among adolescents.

What affects teacher ratings of student behaviors? The potential influence of teachers' perceptions of the school environment and experiences.

Teachers serve as the natural raters of students within the school and classroom contexts. Yet teachers' ratings of their students may vary based on these contextual factors. The current study explored the extent to which teacher perceptions of the school environment predict their longitudinal ratings of student behaviors. Data for this study come from 702 teachers in 42 elementary schools. Teachers self-reported their perceptions of the school context at a single time point, and provided ratings of their students' behavior via the Teacher Observation of Classroom Adaption-Checklist (TOCA-C) across three school years. Latent profile analysis identified three latent classes of teachers based on their ratings of school organizational health, burnout, and efficacy. A regression framework demonstrated an association between the baseline profiles in relation to TOCA-C ratings of student behavior across 3 years. Teachers with more favorable perceptions of the environment had lower initial ratings of concentration problems, disruptive behavior, and internalizing symptoms, and higher ratings of prosocial behaviors and family involvement. They also showed slower growth in their ratings of emotion dysregulation and greater increases of their ratings of family involvement over time. This work is particularly important for determining the extent to which teacher ratings may be biased by teacher and contextual factors, and may have implications for the identification of teachers who may rate students poorly over time.

Health Conditions, Education Services, and Transition Planning for Adolescents With Autism.

OBJECTIVE: Our objectives with this study were to describe the frequency of selected cooccurring health conditions and individualized education program (IEP) services and post-high school transition planning for adolescents with autism spectrum disorder and identify disparities by sex, intellectual ability, race or ethnicity, and geographic area. METHODS: The study sample included 1787 adolescents born in 2004 who were identified as having autism through a health and education record review through age 16 years in 2020. These adolescents were part of a longitudinal population-based surveillance birth cohort from the Autism and Developmental Disabilities Monitoring Network from 2004 to 2020 in 5 US catchment areas. RESULTS: Attention deficit hyperactivity disorder (47%) and anxiety (39%) were the most common cooccurring health conditions. Anxiety was less commonly identified for those with intellectual disability than those without. It was also less commonly identified among Black adolescents compared with White or Hispanic adolescents. There was wide variation across Autism and Developmental Disabilities Monitoring Network sites in the provision of school-based IEP services. Students with intellectual disability were less likely to receive school-based mental health services and more likely to have a goal for postsecondary independent living skills compared with those without intellectual disability. A total of 37% of students did not participate in standardized testing. CONCLUSIONS: We identified disparities in the identification of cooccurring conditions and school-based IEP services, practices, and transition planning. Working with pediatric health and education providers, families, and adolescents with autism will be important to identify contributing factors and to focus efforts to reduce disparities in the supports and services adolescents with autism have access to and receive.

Cultural Adaptation of the teen Mental Health First Aid (tMHFA) Program from Australia to the USA.

teen Mental Health First Aid (tMHFA) is an evidence-based program developed in Australia that teaches young people in grades 10-12 how to identify and respond to signs of mental health challenges and crises among peers. Recognizing the growing adolescent mental health crisis in the USA, the National Council for Mental Wellbeing, in partnership with a Johns Hopkins University research team, used a multimethod research approach to adapt the program culturally and contextually from Australia to the USA. The goals of the study were to engage adolescents, MHFA instructors, and content area experts (N = 171) in a process to determine: how to retain the elements of the course that were evidence-based and effective while adapting the program for US students, what topics to add so US students have the essential information and skills teens needed to help a friend experiencing a mental health challenge or crisis, what changes to make to curriculum materials to ensure the style and delivery resonate with US students, and what tools to include so the program is implemented safely and with fidelity in diverse US schools. This paper outlines the adaptation process, including engaging participants, identifying key recommendations for modification, and making changes to the tMHFA program. The findings demonstrate the types of adaptations that may be needed to facilitate implementation and maintenance of program effectiveness when introducing tMHFA to new populations of students in the USA. In addition, the process outlined can be replicated toward this purpose as the program continues to expand both in the USA and in other countries.

Individualized Education Programs and Transition Planning for Adolescents With Autism.

OBJECTIVES: The study objectives were to examine the contents of individualized education programs (IEPs) of adolescents with autism spectrum disorder (ASD), including postsecondary transition goals, services, and changes in special education classification over time. METHODS: This study involved a longitudinal population-based surveillance cohort from the Autism Developmental Disabilities Monitoring Network from 2002 to 2018 in 3 catchment areas in the United States. The sample included 322 adolescents who were born in 2002, identified with ASD, and had an IEP available for review at ages 15-16 years. RESULTS: We found that 297 (92%) adolescents with ASD had an IEP including a transition plan. Those without intellectual disability (ID) were more likely to have postsecondary education and employment goals and have those goals be to pursue higher education or competitive employment compared with those with ID. Forty-one percent of adolescents with ASD had a postsecondary living arrangement goal. Although 28% of adolescents with ASD received school-based mental health services, none of these adolescents were Black; additionally, 15% of those with ID received mental health services compared with 34% without ID. The percentage of adolescents with ASD served under an autism classification increased from 44% at age 8 years to 62% by age 16. CONCLUSIONS: We identified gaps and disparities in school-based postsecondary transition planning. Working with education partners, families, and adolescents will be important to identify what challenges contribute to these findings and what supports are needed to improve the equity and quality of the transition planning process for adolescents with ASD so they are prepared for adulthood.

Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2020.

Problem/Condition: Autism spectrum disorder (ASD). Period Covered: 2020. Description of System: The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance program that provides estimates of the prevalence of ASD among children aged 8 years. In 2020, there were 11 ADDM Network sites across the United States (Arizona, Arkansas, California, Georgia, Maryland, Minnesota, Missouri, New Jersey, Tennessee, Utah, and Wisconsin). To ascertain ASD among children aged 8 years, ADDM Network staff review and abstract developmental evaluations and records from community medical and educational service providers. A child met the case definition if their record documented 1) an ASD diagnostic statement in an evaluation, 2) a classification of ASD in special education, or 3) an ASD International Classification of Diseases (ICD) code. Results: For 2020, across all 11 ADDM sites, ASD prevalence per 1,000 children aged 8 years ranged from 23.1 in Maryland to 44.9 in California. The overall ASD prevalence was 27.6 per 1,000 (one in 36) children aged 8 years and was 3.8 times as prevalent among boys as among girls (43.0 versus 11.4). Overall, ASD prevalence was lower among non-Hispanic White children (24.3) and children of two or more races (22.9) than among non-Hispanic Black or African American (Black), Hispanic, and non-Hispanic Asian or Pacific Islander (A/PI) children (29.3, 31.6, and 33.4 respectively). ASD prevalence among non-Hispanic American Indian or Alaska Native (AI/AN) children (26.5) was similar to that of other racial and ethnic groups. ASD prevalence was associated with lower household income at three sites, with no association at the other sites.Across sites, the ASD prevalence per 1,000 children aged 8 years based exclusively on documented ASD diagnostic statements was 20.6 (range = 17.1 in Wisconsin to 35.4 in California). Of the 6,245 children who met the ASD case definition, 74.7% had a documented diagnostic statement of ASD, 65.2% had a documented ASD special education classification, 71.6% had a documented ASD ICD code, and 37.4% had all three types of ASD indicators. The median age of earliest known ASD diagnosis was 49 months and ranged from 36 months in California to 59 months in Minnesota.Among the 4,165 (66.7%) children with ASD with information on cognitive ability, 37.9% were classified as having an intellectual disability. Intellectual disability was present among 50.8% of Black, 41.5% of A/PI, 37.8% of two or more races, 34.9% of Hispanic, 34.8% of AI/AN, and 31.8% of White children with ASD. Overall, children with intellectual disability had earlier median ages of ASD diagnosis (43 months) than those without intellectual disability (53 months). Interpretation: For 2020, one in 36 children aged 8 years (approximately 4% of boys and 1% of girls) was estimated to have ASD. These estimates are higher than previous ADDM Network estimates during 2000-2018. For the first time among children aged 8 years, the prevalence of ASD was lower among White children than among other racial and ethnic groups, reversing the direction of racial and ethnic differences in ASD prevalence observed in the past. Black children with ASD were still more likely than White children with ASD to have a co-occurring intellectual disability. Public Health Action: The continued increase among children identified with ASD, particularly among non-White children and girls, highlights the need for enhanced infrastructure to provide equitable diagnostic, treatment, and support services for all children with ASD. Similar to previous reporting periods, findings varied considerably across network sites, indicating the need for additional research to understand the nature of such differences and potentially apply successful identification strategies across states.