Review
Systematic Review: United States Workforce for Autism-Related Child Healthcare Services

https://doi.org/10.1016/j.jaac.2019.04.027Get rights and content

Objective

A diversity of health professional disciplines provide services for children with autism spectrum disorder (ASD) in the United States. We conducted a systematic review examining the availability, distribution, and competencies of the US workforce for autism-related child health care services, and assess studies’ strength of evidence.

Method

We searched PubMed, PsychINFO, Embase, and Google Scholar from 2008 to 2018 for relevant US-based studies. Two investigators independently screened and evaluated studies against a set of prespecified inclusion criteria and evaluated strength of evidence (SOE) using a framework designed to integrate a mixed-methods research.

Results

Of 754 records identified, 33 studies (24 quantitative, 6 qualitative, and 3 mixed-methods) were included. Strength of evidence associated was low-to-moderate, with only 8 studies (24%) satisfying criteria for strong SOE. Geographies and provider cadres varied considerably. The most common specialties studied were pediatricians (n = 13), occupational therapists (n = 12), speech therapists (n = 11), physical therapists (n = 10), and child psychiatrists (n = 8). Topical areas included the following: provider availability by service area and care delivery model; qualitative assessments of provider availability and competency; role of insurance mandates in increasing access to providers: and disparities in access. Across provider categories, we found that workforce availability for autism-related services was limited in terms of overall numbers, time available, and knowledgeability. The greatest unmet need was observed among minorities and in rural settings. Most studies were short term, were limited in scope, and used convenience samples.

Conclusion

There is limited evidence to characterize the availability and distribution of the US workforce for autism-related child health care services. Existing evidence to date indicates significantly restricted availability.

Section snippets

Search Strategy and Selection Criteria

We conducted a systematic review of academic literature, in accordance with PRISMA guidelines,17 shown in Supplement 1, available online, targeting peer-reviewed publications. Inclusion criteria were as follows: (1) topically focused on availability and/or distribution of health workforce, including health workforce ability and competency to provide autism-related health services; (2) included one or more of the following nine health workforce provider categories: child psychiatrists, child

Study Inclusion

After the search procedures, we reviewed 867 records: 861 from database searches, and an additional 6 from bibliographic reviews. There was a high degree of interrater reliability (93%) between screeners regarding inclusion of articles for full-text review, and all discrepancies were reconciled.

Following screening, 74 studies were identified for full-text inspection of eligibility. We excluded 750 studies using a stepwise assessment to eliminate studies in the following order: (1) studies that

Discussion

The 33 studies included in this review identify a number of workforce-related challenges for families seeking treatment for children with ASD—including lack of preparation of primary care providers (PCPs) to serve children with ASD, lack of availability of specialty providers, and disparities in access to ASD services by sociodemographic and geographic factors. Each of these underscores key areas for progress in provider training and deployment.

With regard to the role of PCPs, the evidence

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    This work was supported by the National Institute of Mental Health (NIMH; R01MH112760).

    Dr. McBain served as the statistical expert for this research.

    The authors would like to thank Aaron Kofner, MS, of the RAND Corporation, for his involvement in the early conceptualization of this manuscript. They would also like to thank those authors who made the construction of this manuscript possible by conducting research on the availability and quality of autism-related child healthcare services in the US.

    Disclosure: Dr. McBain has received research support from NIMH, the Assistant Secretary for Planning and Evaluation, the Health Resources and Services Administration, the Centers for Medicare and Medicaid Services, the Los Angeles County Department of Mental Health, and the US Department of Defense. He is a member of the advisory board of Water Ecuador. Dr. Cantor has received research support from NIMH, the National Cancer Institute, the Pew Charitable Trusts, Los Angeles County, the Centers for Medicare and Medicaid Services, the US Department of Defense, and the Social Security Administration. Dr. Stein has received support from NIMH, the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, the National Institute on Minority Health and Health Disparities, the National Institute of Dental and Craniofacial Research, and the National Institute on Alcohol Abuse and Alcoholism. Dr. Yu has received support from NIMH, the National Institute of Minority Health and Health Disparities, and the Agency for Healthcare Research and Quality. Ms. Kareddy has received research support from the United States – India Educational Foundation.

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