Employing user-centered design to develop a remote technology kit for studying young children's social communication skills.

OBJECTIVE: The COVID-19 pandemic required behavioral researchers to rapidly pivot to the implementation of remote study protocols to facilitate data collection. Remote implementation required robust and flexible research protocols including reliable audio/visual technology that met all the quality, security, and privacy hallmarks of lab-based equipment, while also being portable and usable by nontechnical staff and participants. The project's primary purpose was to develop a technology kit that could be deployed for data collection in homes with young children. The secondary objective was to determine the feasibility of the kit for use longitudinally across four disparate sites. METHOD: User-centered design principles were employed in the development and implementation of a technology kit deployed across urban, suburban, and rural participant locations in four states. Preliminary feasibility and usability data were gathered to determine the reliability of the kit across three timepoints. RESULTS: In study 1, a technology kit was constructed addressing all project needs including the provision of the internet to connect remotely with participants. Staff training protocols and participant-facing materials were developed to accompany deployment procedures. In study 2, data gathered in technology logs demonstrated successful capturing of video footage in 96% of opportunities with most technology challenges mitigated. Subsequent behavioral coding indicated 100% of captured assessment footage has been successfully coded to date. Moreover, participants needed less support for technology setup at their later timepoints, and staff rated the kit as highly usable. CONCLUSION: This study offers a model for future development of technology use in remote community- and home-based pediatric research.

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.

Longevity of immune response after a single dose of typhoid conjugate vaccine against Salmonella Typhi among children in Hyderabad, Pakistan.

OBJECTIVES: Typhoid remains a persistent contributor to childhood morbidity in communities lacking sanitation infrastructure. Typhoid conjugate vaccine (TCV) is effective in reducing disease risk in vaccinees; however, the duration of protection is unknown. This study measured the longevity of immune response to TCV in children aged under 10 years in Hyderabad, Pakistan, where an outbreak of extensively drug-resistant typhoid has been ongoing. METHODS: A subset of children who received the TCV as part of the outbreak response were enrolled purposively from March 2018 to February 2019. The participants were followed up until January 2023. Blood samples were taken at baseline, 4-6 weeks, 6 months, and annually 1-4 years after vaccination to measure anti-Vi immunoglobulin (Ig) G levels using enzyme-linked immunosorbent assay. Active phone-based surveillance was performed to identify breakthrough infections. Blood culture was offered to any child with a history of fever ≥3 days within the last 7 days. A total of 81 children received a second dose of TCV in November 2019 during a catch-up campaign organized by the Sindh government. RESULTS: Nearly all participants seroconverted (802 of 837; 95.8%) at 4-6 weeks after vaccination. A total of 4 years after vaccination, 438 of 579 (75.6%) participants remained above the seroconversion threshold. The geometric mean titer (U/mL) of anti-Vi IgG at 4-6 weeks was 832.6 (95% confidence interval [CI]: 768.0-902.6); at 4 years after vaccination, the geometric mean titers in children aged 6 months to 2 years (12.6, [95% CI: 9.8-16.3]) and >2-5 years (40.1, [95% CI: 34.4-46.6]) were lower than in children aged >5-10 years (71.1, [95% CI: 59.5-85.0]). During 4 years of follow-up, nine children had culture-confirmed Salmonella Typhi infection; these infections occurred after a median duration of 3.4 years. All enteric fever cases seroconverted at 4-6 weeks after vaccination and seven (70.0%) remained seroconverted 4 years after vaccination. CONCLUSIONS: We observed 95.8% seroconversion after a single dose of TCV. There was a decay in anti-Vi IgG titers, and, at 4 years, approximately 75.6% remained seroconverted. There was a faster decay in children aged ≤2 years. Breakthrough infections were documented after a median 3.4 years after vaccination.

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.

Mother-Infant Interaction and Maternal Postnatal Psychological Distress Associate with Child's Social-Emotional Development During Early Childhood: A FinnBrain Birth Cohort Study.

We studied the effects of mother-infant interaction and maternal pre- and postnatal psychological distress on children's social-emotional problems and competences, as well as whether interaction quality moderates the association between distress and children's outcomes. Maternal pre- and postnatal psychological distress were measured using the SCL and EPDS questionnaires, whereas mother-infant interaction was measured when the child was 8 months old using the EA Scales. Children's social-emotional development was measured using the BITSEA questionnaire at 2 years old and using the SDQ questionnaire at 4 years old, where higher maternal structuring was associated with fewer social-emotional problems in children and higher maternal sensitivity was associated with greater social-emotional competence in children at 2 years old. Further, higher postnatal distress was found associated with greater social-emotional problems at 2 years old, though neither these effects nor moderating effects at 4 years old were observed after multiple-comparison corrections. Our findings support direct associations of both mother-infant interaction and maternal postnatal psychological distress with children's social-emotional development during toddlerhood.

Child social-emotional and behavioral problems and competencies contribute to changes in developmental functioning during Early Intervention.

This study examined how social-emotional and behavioral (SEB) problems and competencies contribute to changes in developmental functioning among children enrolled in Part C Early Intervention (EI), a U.S. program supporting young children with developmental delays and disabilities. The sample included 1,055 children enrolled in EI from 2011-2019 (mean age at EI entry = 17 months; 64% male; 72% marginalized racial and ethnic backgrounds). Standardized developmental assessments, drawn from administrative records, characterized developmental functioning at EI entry and exit and parents reported SEB functioning. Hierarchical regression analyses revealed that SEB problems and competencies interacted in predicting change in developmental functioning from EI entry to exit. Monitoring, identifying, and addressing SEB problems and competencies may optimize developmental outcomes for young children with developmental delays and disabilities.

Negative associations between maternal prenatal hair cortisol and child socioemotional problems.

Maternal prenatal distress can participate in the programming of offspring development, in which exposure to altered maternal long-term cortisol levels as measured by hair cortisol concentrations (HCC) may contribute. Yet, studies investigating whether and how maternal prenatal HCC associates with problems in child socioemotional development are scarce. Furthermore, questions remain regarding the timing and potential sex-specificity of fetal exposure to altered cortisol levels and whether there are interactions with maternal prenatal distress, such as depressive symptoms. The subjects were drawn from those FinnBrain Birth Cohort families that had maternal reports of child socioemotional problems (the Brief Infant-Toddler Social and Emotional Assessment [BITSEA] at 2 years and/or the Strengths and Difficulties Questionnaire [SDQ] at 5 years) as follows: HCC1 population: maternal mid-pregnancy HCC measured at gestational week 24 with 5 cm segments to depict cortisol levels from the previous five months (n = 321); and HCC2 population: end-of-pregnancy HCC measured 1-3 days after childbirth (5 cm segment; n = 121). Stepwise regression models were utilized in the main analyses and a sensitivity analysis was performed to detect potential biases. Negative associations were observed between maternal HCC2 and child BITSEA Total Problems at 2 years but not with SDQ Total difficulties at 5 years, and neither problem score was associated with HCC1. In descriptive analyses, HCC2 was negatively associated with Internalizing problems at 2 years and SDQ Emotional problems at 5 years. A negative association was observed among 5-year-old girls between maternal HCC1 and SDQ Total Difficulties and the subscales of Conduct and Hyperactivity/inattentive problems. When interactions were also considered, inverse associations between HCC2 and BITSEA Internalizing and Dysregulation Problems were observed in subjects with elevated prenatal depressive symptoms. It was somewhat surprising that only negative associations were observed between maternal HCC and child socioemotional problems. However, there are previous observations of elevated end-of-pregnancy cortisol levels associating with better developmental outcomes. The magnitudes of the observed associations were, as expected, mainly modest. Future studies with a focus on the individual changes of maternal cortisol levels throughout pregnancy as well as studies assessing both maternal and child HPA axis functioning together with child socioemotional development are indicated.

The influence of loss to follow-up in autism screening research: Taking stock and moving forward.

BACKGROUND: How best to improve the early detection of autism spectrum disorder (ASD) is the subject of significant controversy. Some argue that universal ASD screeners are highly accurate, whereas others argue that evidence for this claim is insufficient. Relatedly, there is no clear consensus as to the optimal role of screening for making referral decisions for evaluation and treatment. Published screening research can meaningfully inform these questions-but only through careful consideration of children who do not complete diagnostic follow-up. METHODS: We developed two simulation models that re-analyze the results of a large-scale validation study of the M-CHAT-R/F by Robins et al. (2014, Pediatrics, 133, 37). Model #1 re-analyzes screener accuracy across six scenarios, each reflecting different assumptions regarding loss to follow-up. Model #2 builds on this by closely examining differential attrition at each point of the multi-step detection process. RESULTS: Estimates of sensitivity ranged from 40% to 94% across scenarios, demonstrating that estimates of accuracy depend on assumptions regarding the diagnostic status of children who were lost to follow-up. Across a range of plausible assumptions, data also suggest that children with undiagnosed ASD may be more likely to complete follow-up than children without ASD, highlighting the role of clinicians and caregivers in the detection process. CONCLUSIONS: Using simulation modeling as a quantitative method to examine potential bias in screening studies, analyses suggest that ASD screening tools may be less accurate than is often reported. Models also demonstrate the critical importance of every step in a detection process-including steps that determine whether children should complete an additional evaluation. We conclude that parent and clinician decision-making regarding follow-up may contribute more to detection than is widely assumed.

Higher attention bias for fear at 8 months of age is associated with better socioemotional competencies during toddlerhood.

BACKGROUND: In previous studies, an attention bias for signals of fear and threat has been related to socioemotional problems, such as anxiety symptoms, and socioemotional competencies, such as altruistic behaviors in children, adolescents and adults. However, previous studies lack evidence about these relations among infants and toddlers. AIMS: Our aim was to study the association between the individual variance in attention bias for faces and, specifically, fearful faces during infancy and socioemotional problems and competencies during toddlerhood. STUDY DESIGN AND SUBJECTS: The study sample was comprised of 245 children (112 girls). We explored attentional face and fear biases at the age of 8 months using eye tracking and the face-distractor paradigm with neutral, happy and fearful faces and a scrambled-face control stimulus. Socioemotional problems and competencies were reported by parents with the Brief Infant and Toddler Social Emotional Assessment (BITSEA) when children were 24 months old. OUTCOME MEASURES AND RESULTS: A higher attentional fear bias at 8 months of age was related to higher levels of socioemotional competence at 24 months of age (ß = .18, p = .008), when infants' sex and temperamental affectivity, maternal age, education and depressive symptoms were controlled. We found no significant association between attentional face or fear bias and socioemotional problems. CONCLUSIONS: We found that the heightened attention bias for fearful faces was related to positive outcomes in early socioemotional development. Longitudinal study designs are needed to explore the changes in the relation between the attention bias for fear or threat and socioemotional development during early childhood.

Reciprocal Associations Between Language Ability and Social Functioning Development in Pre-verbal Autistic Children.

Longitudinal research on language abilities and social functioning in young children suggests that gains in one domain affect gains in the other. However, few studies have examined inter-relations of language and social functioning jointly among young children diagnosed with autism spectrum disorder (ASD). Pre-verbal toddlers with ASD are a group of particular clinical relevance, given that greater language abilities at school entry have been associated with positive long-term adjustment in many areas, including adaptive and social functioning. Reduced attention to and engagement in social interactions among autistic toddlers who are not yet speaking may interfere with language development concurrently and over time. The present study examined reciprocal associations between language ability and social functioning over a 2-year period across three time points in a sample of 90 pre-verbal autistic toddlers using cross-lagged panel analyses conducted in MPlus. Cross-lagged panel analyses revealed significant within-timepoint synchronous correlations, within-domain autoregressive paths over time, and as hypothesized, reciprocal significance in all cross-lagged paths. For very young pre-verbal children with ASD, language ability and social functioning appear to exert concurrent and cascading developmental influences on one another. Targeting both language and social functioning simultaneously may enhance intervention efficacy for very young pre-verbal children with ASD.

Prevalence and Co-Occurrence of Developmental and Emotional-Behavioral Problems in Young Children.

OBJECTIVE: A limited number of studies have estimated the prevalence of emotional-behavioral disorders among young children. None have assessed their co-occurrence with developmental delays using standardized assessment tools. Our objective was to estimate the prevalence of emotional-behavioral disorders and their co-occurrence with developmental delays among young children (2-5.5 years). METHODS: Parents of young children (N = 987) enrolled from pediatric waiting rooms completed developmental-behavioral screening questionnaires. Based on results, 585 families were invited to and 439 completed evaluations that included structured diagnostic interviews with parents to assess child psychopathology (Preschool Age Psychiatric Assessment (PAPA)), developmental testing with children (including the Bayley Scales of Infant and Toddler Development, third Edition for children ≤ 42 months; Differential Ability Scales, second Edition for older children), and videotaped observation to establish whether autism risk was sufficient to warrant further evaluation. RESULTS: According to PAPA algorithms, 23.0% of children met criteria for a DSM-IV disorder, while 9% qualified for a developmental delay. Presence of delay doubled the odds of having a DSM-IV disorder (OR = 2.1; CI: 1.02-4.3), and presence of disorder doubled the odds of having a moderate-to-severe developmental delay (OR=2.0; CI: 1.10-3.50). Prevalence of DSM-IV disorders (48.8% (95% CI: 33.5-64.5%)) and developmental delays (57.5% (95% CI: 41.7-71.9%)) were both higher among children at risk for autism. While developmental delay did not vary by race/ethnicity, prevalence of DSM-IV disorders was lower among African-American/Black (10.6%; CI: 2.9-18.3) and Hispanic/Latino children (11.1%; CI: 4.3-17.9). CONCLUSIONS: Developmental delays and emotional-behavioral disorders among young children seen in pediatric settings are characterized by high prevalence and substantial co-occurrence.

Characterizing Accommodations by Parents of Young Children with Autism: A Mixed Methods Analysis.

Symptoms of autism influence families' participation in daily activities, but few studies have broadly explored the types of accommodations caregivers make to their family's routines after their child is diagnosed with autism. The current study used a mixed-methods approach to characterize the rate and types of accommodations made by 171 families and the child and family characteristics that predicted accommodations. Most families (91%) endorsed making accommodations in the past year. Lower income, older child age, marginalized racial/ethnic identity, and higher levels of child problem behavior predicted accommodations in a greater number of domains. Thematic analysis illuminated the types of accommodations caregivers made and their motivation for making these lifestyle adjustments. Findings have important implications for parent-mediated interventions and policy.

Screening Infants Through Adolescents for Social/Emotional/Behavioral Problems in a Pediatric Network.

OBJECTIVE: To assess changes in screening completion in a diverse, 7-clinic network after making annual screening for social/emotional/behavioral (SEB) problems the standard of care for all infant through late adolescent-aged patients and rolling out a fully automated screening system tied to the electronic medical record and patient portal. METHODS: In 2017, the Massachusetts General Hospital made SEB screening using the age-appropriate version of the Pediatric Symptom Checklist the standard of care in its pediatric clinics for all patients aged 2.0 months to 17.9 years. Billing records identified all well-child visits between January 1, 2016 and December 31, 2019. For each visit, claims were searched for billing for an SEB screen and the electronic data warehouse was queried for an electronically administered screen. A random sample of charts was reviewed for other evidence of screening. Chi-square analyses and generalized estimating equations assessed differences in screening over time and across demographic groups. RESULTS: Screening completion (billing and/or electronic) significantly increased from 2016 (37.2%) through 2019 (2017 [46.2%] vs 2018 [66.8%] vs 2019 [70.9%]; χ2 (3) =112652.33, P < .001), with an even higher prevalence found after chart reviews. Most clinics achieved screening levels above 90% by the end of 2019. Differences among demographic groups were small and dependent on whether data were aggregated at the clinic or system level. CONCLUSIONS: Following adoption of a best-practice policy and implementation of an electronic system, SEB screening increased in all age groups and clinics. Findings demonstrate that the AAP recommendation for routine psychosocial assessment is feasible and sustainable.

Bilingual and Monolingual Autistic Toddlers: Language and Social Communication Skills.

Parents of children diagnosed with autism spectrum disorders (ASD) express concern about raising their children bilingually, and often hear advice from professionals against the use of bilingualism. The current study examined the relation between bilingualism and the language and social communication skills of toddlers diagnosed with ASD (N = 353) in the US, while controlling for socioeconomic risk factors. Structural equation modeling showed no differences in language skills between bilingual Spanish-English speaking children and monolingual English-speaking (p = .596) or monolingual Spanish-speaking (p = .963) children and showed a bilingual advantage on socialization skills when comparing bilingual and monolingual English-speaking children (p = .001). Parents of autistic children exposed to Spanish and English should be encouraged to raise their child bilingually if it best suits familial needs.

Delays in autism diagnosis for U.S. Spanish-speaking families: The contribution of appointment availability.

Promoting equity in health services requires an understanding of the mechanisms that produce disparities. Utilizing a sequential, mixed-methods, explanatory study design, we analyzed child-, family-, and organizational-level factors and their association with wait times for an ASD diagnostic evaluation among 353 families scheduled for English and Spanish language appointments (27% Spanish language). A subset of parents and caregivers participated in English and Spanish language focus groups to provide their perspectives on the diagnostic process. Spanish language was associated with greater completion of, and time to evaluations than English language. The only variable found to mediate associations with time-to-evaluation was appointment availability - an organizational factor. Qualitative results elucidate potential explanations for greater Spanish language evaluation completion (e.g., fewer community-based diagnostic options). Results serve as a case study to support the utility and importance of analyzing the influence of organizational-level factors on delays and disparities for childhood health and mental health services. We discuss our findings in relation to strategies that can be widely applied to support equitable services access for childhood diagnostic and intervention services.

Incidence of typhoid and paratyphoid fever in Bangladesh, Nepal, and Pakistan: results of the Surveillance for Enteric Fever in Asia Project.

BACKGROUND: Precise enteric fever disease burden data are needed to inform prevention and control measures, including the use of newly available typhoid vaccines. We established the Surveillance for Enteric Fever in Asia Project (SEAP) to inform these strategies. METHODS: From September, 2016, to September, 2019, we conducted prospective clinical surveillance for Salmonella enterica serotype Typhi (S Typhi) and Paratyphi (S Paratyphi) A, B, and C at health facilities in predetermined catchment areas in Dhaka, Bangladesh; Kathmandu and Kavrepalanchok, Nepal; and Karachi, Pakistan. Patients eligible for inclusion were outpatients with 3 or more consecutive days of fever in the last 7 days; inpatients with suspected or confirmed enteric fever; patients with blood culture-confirmed enteric fever from the hospital laboratories not captured by inpatient or outpatient enrolment and cases from the laboratory network; and patients with non-traumatic ileal perforation under surgical care. We used a hybrid surveillance model, pairing facility-based blood culture surveillance with community surveys of health-care use. Blood cultures were performed for enrolled patients. We calculated overall and age-specific typhoid and paratyphoid incidence estimates for each study site. Adjusted estimates accounted for the sensitivity of blood culture, the proportion of eligible individuals who consented and provided blood, the probability of care-seeking at a study facility, and the influence of wealth and education on care-seeking. We additionally calculated incidence of hospitalisation due to typhoid and paratyphoid. FINDINGS: A total of 34 747 patients were enrolled across 23 facilitates (six tertiary hospitals, surgical wards of two additional hospitals, and 15 laboratory network sites) during the study period. Of the 34 303 blood cultures performed on enrolled patients, 8705 (26%) were positive for typhoidal Salmonella. Adjusted incidence rates of enteric fever considered patients in the six tertiary hospitals. Adjusted incidence of S Typhi, expressed per 100 000 person-years, was 913 (95% CI 765-1095) in Dhaka. In Nepal, the adjusted typhoid incidence rates were 330 (230-480) in Kathmandu and 268 (202-362) in Kavrepalanchok. In Pakistan, the adjusted incidence rates per hospital site were 176 (144-216) and 103 (85-126). The adjusted incidence rates of paratyphoid (of which all included cases were due to S Paratyphi A) were 128 (107-154) in Bangladesh, 46 (34-62) and 81 (56-118) in the Nepal sites, and 23 (19-29) and 1 (1-1) in the Pakistan sites. Adjusted incidence of hospitalisation was high across sites, and overall, 2804 (32%) of 8705 patients with blood culture-confirmed enteric fever were hospitalised. INTERPRETATION: Across diverse communities in three south Asian countries, adjusted incidence exceeded the threshold for "high burden" of enteric fever (100 per 100 000 person-years). Incidence was highest among children, although age patterns differed across sites. The substantial disease burden identified highlights the need for control measures, including improvements to water and sanitation infrastructure and the implementation of typhoid vaccines. FUNDING: Bill & Melinda Gates Foundation.

Estimating typhoid incidence from community-based serosurveys: a multicohort study.

BACKGROUND: The incidence of enteric fever, an invasive bacterial infection caused by typhoidal Salmonellae (Salmonella enterica serovars Typhi and Paratyphi), is largely unknown in regions without blood culture surveillance. The aim of this study was to evaluate whether new diagnostic serological markers for typhoidal Salmonella can reliably estimate population-level incidence. METHODS: We collected longitudinal blood samples from patients with blood culture-confirmed enteric fever enrolled from surveillance studies in Bangladesh, Nepal, Pakistan, and Ghana between 2016 and 2021 and conducted cross-sectional serosurveys in the catchment areas of each surveillance site. We used ELISAs to measure quantitative IgA and IgG antibody responses to hemolysin E and S Typhi lipopolysaccharide. We used Bayesian hierarchical models to fit two-phase power-function decay models to the longitudinal antibody responses among enteric fever cases and used the joint distributions of the peak antibody titres and decay rate to estimate population-level incidence rates from cross-sectional serosurveys. FINDINGS: The longitudinal antibody kinetics for all antigen-isotypes were similar across countries and did not vary by clinical severity. The seroincidence of typhoidal Salmonella infection among children younger than 5 years ranged between 58·5 per 100 person-years (95% CI 42·1-81·4) in Dhaka, Bangladesh, to 6·6 per 100 person-years (4·3-9·9) in Kavrepalanchok, Nepal, and followed the same rank order as clinical incidence estimates. INTERPRETATION: The approach described here has the potential to expand the geographical scope of typhoidal Salmonella surveillance and generate incidence estimates that are comparable across geographical regions and time. FUNDING: Bill & Melinda Gates Foundation. TRANSLATIONS: For the Nepali, Bengali and Urdu translations of the abstract see Supplementary Materials section.

Effectiveness of Screening in Early Intervention Settings to Improve Diagnosis of Autism and Reduce Health Disparities.

IMPORTANCE: The American Academy of Pediatrics recommends referring children at elevated risk of autism spectrum disorder (ASD) for Part C early intervention (EI) services, but notes that EI services often fail to provide ASD screening. OBJECTIVE: To evaluate the hypothesis that a multistage screening protocol for ASD implemented in 3 EI settings will increase autism detection, especially among Spanish-speaking families. DESIGN, SETTING, AND PARTICIPANTS: Difference-in-differences analyses with propensity score weighting of a quasi-experimental design using administrative data on 3 implementation EI agencies and 9 comparison EI agencies from 2012 to 2018 provided by the Massachusetts Department of Public Health. Eligible children were aged 14 to 36 months, enrolled in EI, had no prior ASD diagnosis or medical condition precluding participation, and had parents who spoke English or Spanish. The final analytic sample included 33 326 unique patients assessed across 150 200 person-quarters. EXPOSURES: Multistage ASD assessment protocol including ASD screening questionnaires, observational screener, and diagnostic evaluation. MAIN OUTCOMES AND MEASURES: Increased incidence of ASD diagnoses as documented in Department of Public Health records and reductions in language-associated health care disparities. RESULTS: Implementation of screening at 3 EI sites was associated with a significant increase in the rate of ASD diagnoses (incidence rate ratios [IRR], 1.6; 95% CI, 1.3-2.1; P < .001), representing an additional 8.1 diagnoses per 1000 children per quarter. Among Spanish-speaking families, screening was also associated with a significant increase in the rate of ASD diagnoses (IRR, 2.6; 95% CI, 1.6-4.3; P < .001), representing 15.4 additional diagnoses per 1000 children per quarter-a larger increase than for non-Spanish-speaking families (interaction IRR, 1.8; 95% CI, 1.0-3.1; P = .005). Exploratory analyses revealed that screening was associated with a larger increase in the rate of ASD diagnoses among boys (IRR, 1.8; 95% CI, 1.4-2.3; P < .001) than among girls (IRR, 1.1; 95% CI, 0.6-1.7; P = .84). CONCLUSIONS AND RELEVANCE: In this study, associations between increased rates of ASD diagnoses and reductions in disparities for Spanish-speaking households support the effectiveness of multistage screening in EI. This study provides a comprehensive evaluation of ASD screening in EI settings as well as a rigorous evaluation of ASD screening in any setting with a no-screening comparison condition. Given that the intervention included multiple components, mechanisms of action warrant further research, as do disparities by child sex.

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 Taxonomy of Reported Harms in Pediatric Autism Spectrum Disorder Screening: Provider and Parent Perspectives.

The U.S. Preventive Services Task Force (USPSTF) report on screening for Autism Spectrum Disorder (ASD) highlighted the need for research that examines the harms potentially associated with screening so as to assess the overall net benefit of universal screening. In response, this study engages qualitative, semi-structured interviews to generate a taxonomy outlining potential harms reported by parents and providers (pediatricians and Early Intervention providers) with experience in screening young children for ASD. Potential harms emerged including: physical, psychological, social, logistical/financial, opportunity cost, attrition, and exacerbation of non-targeted disparities. Respondents reported harms being experienced by the toddlers, parents, and providers. The harms reported highlight opportunities for providers to offer resources that mitigate the potential for these unintended consequences.