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ABSTRACTPromoting 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.

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.

ABSTRACTThe home physical environment has an important influence on children’s physical activity levels and time spent in sedentary behaviours. The aim of this study was to validate the HomeSPACE-II instrument for use in two-storey homes, to measure physical environmental factors that influence children’s physical activity and sedentary behaviours within the home. Parents (n = 31) with at least one child aged 9–13 years completed the instrument independently alongside a criterion-trained researcher, then one week later alone, to assess validity and reliability, respectively. Parents were mostly female (87.1%) and university educated (61.3%) with a mean age of 41.68 ± 4 years, while houses were mostly semi-detached or terraced (61.3%) with two parents (87.1%). Intra-class correlation coefficients, Pearson correlation coefficients and Kappa statistics revealed that most items, outside of accessibility and size measures, had strong reliability and validity (94% having ICC > 0.60 and 97% having r > 0.80). Excluding physical activity equipment, accessibility items with lower reliability and validity had low between-subject variation. The HomeSPACE-II instrument covers a wide range of parameters within the home and demonstrated strong validity and reliability, suggesting it is a useful tool for measuring physical factors that influence children’s physical activity and sedentary behaviour within the home.

IMPORTANCE: Universal developmental screening is widely recommended, yet studies of the accuracy of commonly used questionnaires reveal mixed results, and previous comparisons of these questionnaires are hampered by important methodological differences across studies. OBJECTIVE: To compare the accuracy of 3 developmental screening instruments as standardized tests of developmental status. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional diagnostic accuracy study recruited consecutive parents in waiting rooms at 10 pediatric primary care offices in eastern Massachusetts between October 1, 2013, and January 31, 2017. Parents were included if they were sufficiently literate in the English or Spanish language to complete a packet of screening questionnaires and if their child was of eligible age. Parents completed all questionnaires in counterbalanced order. Participants who screened positive on any questionnaire plus 10% of those who screened negative on all questionnaires (chosen at random) were invited to complete developmental testing. Analyses were weighted for sampling and nonresponse and were conducted from October 1, 2013, to January 31, 2017. EXPOSURES: The 3 screening instruments used were the Ages & Stages Questionnaire, Third Edition (ASQ-3); Parents’ Evaluation of Developmental Status (PEDS); and Survey of Well-being of Young Children (SWYC): Milestones. MAIN OUTCOMES AND MEASURES: Reference tests administered were Bayley Scales of Infant and Toddler Development, Third Edition, for children aged 0 to 42 months, and Differential Ability Scales, Second Edition, for older children. Age-standardized scores were used as indicators of mild (80-89), moderate (70-79), or severe (<70) delays. RESULTS: A total of 1495 families of children aged 9 months to 5.5 years participated. The mean (SD) age of the children at enrollment was 2.6 (1.3) years, and 779 (52.1%) were male. Parent respondents were primarily female (1325 [88.7%]), with a mean (SD) age of 33.4 (6.3) years. Of the 20.5% to 29.0% of children with a positive score on each questionnaire, 35% to 60% also received a positive score on a second questionnaire, demonstrating moderate co-occurrence. Among younger children (<42 months), the specificity of the ASQ-3 (89.4%; 95% CI, 85.9%-92.1%) and SWYC Milestones (89.0%; 95% CI, 86.1%-91.4%) was higher than that of the PEDS (79.6%; 95% CI, 75.7%-83.1%; P < .001 and P = .002, respectively), but differences in sensitivity were not statistically significant. Among older children (43-66 months), specificity of the ASQ-3 (92.1%; 95% CI, 85.1%-95.9%) was higher than that of the SWYC Milestones (70.7%; 95% CI, 60.9%-78.8%) and the PEDS (73.7%; 95% CI, 64.3%-81.3%; P < .001), but sensitivity to mild delays of the SWYC Milestones (54.8%; 95% CI, 38.1%-70.4%) and of the PEDS (61.8%; 95% CI, 43.1%-77.5%) was higher than that of the ASQ-3 (23.5%; 95% CI, 9.0%-48.8%; P = .012 and P = .002, respectively). Sensitivity exceeded 70% only with respect to severe delays, with 73.7% (95% CI, 50.1%-88.6%) for the SWYC Milestones among younger children, 78.9% (95% CI, 55.4%-91.9%) for the PEDS among younger children, and 77.8% (95% CI, 41.8%-94.5%) for the PEDS among older children. Attending to parents’ concerns was associated with increased sensitivity of all questionnaires. CONCLUSIONS AND RELEVANCE: This study found that 3 frequently used screening questionnaires offer adequate specificity but modest sensitivity for detecting developmental delays among children aged 9 months to 5 years. The results suggest that trade-offs in sensitivity and specificity occurred among the questionnaires, with no one questionnaire emerging superior overall.

The research starts from the premise that as the world is changing rapidly and in nonlinear ways, we are educating future practitioners for jobs and contexts that don’t yet exist. They instead need to be equipped to work for and with uncertainty to be able to grapple with the scale and pace of emergent change. The fields of design and futures studies bring significant insights to this challenge, including an array of methods, tools, and frameworks for prospective and systemic explorations of alternative futures. The emerging field of design futures can be framed as ways to develop and deploy prompts, artifacts, and narratives to critically interrogate tomorrow’s societal debates today; as such, it is intentional from the outset in its pursuit of preferable futures and therefore social and environmental justice. The process of imagining the future is an active, values-laden social practice, which requires a layered approach to a methodology to surface and challenge dominant patterns—making it an ideal approach for training the young people who will shape our future. This article reports on the design and delivery of participatory workshops that employ design futures methods to facilitate the exploration of transformative change for sustainability. These workshops were conducted with young people aged sixteen to seventeen to equip them to develop and explore alternative futures. The results suggest that design futures methods can facilitate participants from non-design backgrounds to develop alternative futures and artifacts that might sit within them. It was found that developing a sense of ownership was key to enabling participants to effectively reflect on alternative futures and their implications. Finally, the study highlights the potential for these methods to inform both design and sustainability pedagogy.