Current prevalence estimates indicate that autism spectrum disorder (ASD) affects 1 in 36 children in the United States (1). Although social communication difficulties, including difficulties understanding how to initiate or maintain social interaction or social relationships with others, and restrictive and/or repetitive behaviors are the core impairments of ASD, co-occurring mental health problems are highly prevalent within this population, with anxiety and externalizing symptoms the most common and impairing (2, 3). Indeed, anxiety is one of the most common presenting problems for autistic individuals (4), with as many as 69% of autistic youth experiencing clinically significant anxiety disorders (5). Further, externalizing behaviors (including aggression, tantrums, self-injurious behaviors, noncompliance, and elopement) are also one of the most prevalent problems for this population, with 53% to 68% of autistic youth demonstrating aggression or tantrums (6–8). Resultingly, autistic youth have elevated service needs due to the chronicity and severity of ASD core symptoms and co-occurring mental health problems, particularly for youth co-presenting with social difficulties, externalizing behaviors, or anxiety symptoms (9, 10). However, there exists a well-known gap between intervention research and community-based practice for autistic youth and their families (11–16), particularly in community settings (e.g., community mental and behavioral health clinics, schools, private outpatient therapy or treatment clinics) providing services to school-age autistic youth (13, 17). Due to this gap, autistic youth experience high rates of unmet mental and behavioral health needs (18).

Several factors contribute to this research-to-practice gap, including a paucity of trained community-based providers; child, family and provider characteristics, and a lack of compatibility between interventions studied within research settings—that tend to focus on intervention efficacy—and community-based practice settings (11, 12, 15, 19). Indeed, community-based service organizations vary in terms of policy, organizational structure, and funding, which further contributes to challenges in translating interventions to these settings (12, 20) or understanding what the landscape of services entails within the U.S. e.g., which practices are being systematically used, underused, or mis-implemented; (21) and by whom (e.g., provider discipline, education, training, license, etc.). For example, autistic youth receive intervention services in many different settings (e.g., school, outpatient clinics in hospitals/medical centers, community mental health centers, research centers, private practice) and from providers representing a wide array of disciplines including behavior therapists, psychologists, social workers, educators, pediatricians, nurses, neurologists, and – most commonly – allied health professionals including speech language therapists and occupational therapists (22, 23). These disciplines have varied education levels, training backgrounds, and therapeutic orientations, may use different standards for evaluating the efficacy and effectiveness of practices, and may use different intervention practices and/or different terminology to describe those strategies, all of which result in differing approaches to routine or “usual” care found in the community (22). Further, this service landscape often results in siloed or fragmented care (22, 24, 25). In particular, the different terminology used by different disciplines can make communication across disciplines challenging, as they “speak different languages” (26, p. 374). This variability of professionals and service settings may lead to inconsistent implementation of practices for autistic youth and their families, and variable communication between providers within different systems of care; to date, even identifying such inconsistency has proven difficult due to the vast array of practices, practitioners, and settings (27, 28). Therefore, to begin to bridge the research-practice gap, a vital question remains underexamined: which individual intervention practices (or coherent groups thereof) are being used to treat autistic youth, by whom, and in what settings (i.e., what is the landscape of practices in the United States)? Understanding the practice landscape within community-based, usual care settings will allow us to promote a common vocabulary of treatment practices, facilitate improved communication and coordination of care, and enact effective implementation strategies to support evidence-based practice uptake and sustained use as well as de-implementation of nonevidence-based or unacceptable practices within this provider population (13, 20, 29, 30).

Implementation science (IS) provides methods for active, intentional efforts to embed clinical practices within organizations or service systems (31). A primary goal of IS is to maximize the fit, feasibility, acceptability, and utility of practices within implementation settings (32). Therefore, a comprehensive understanding of the existing service landscape (i.e., provider use of practices) for treating common mental and behavioral health concerns experienced by autistic youth is a critical first step that will lead to identifying and utilizing implementation strategies to improve the quality of ASD services in community-based settings (33). Moreover, it is crucial to first identify transdisciplinary treatment practices, defined as psychosocial treatment practices used by providers from two or more disciplines, in community-based settings regardless of empirical support status. Identification of transdisciplinary treatment practices are thought to: (1) increase the generalizability of effective implementation strategies (e.g., training protocols, fidelity measures, consistency across service settings) that facilitate the adoption and utilization of these practices, and (2) allow for more individualized, modular approaches to selection and use of these practices despite the discipline that developed the practice (34, 35). Empirically categorizing these discrete practices into groups of transdisciplinary “practice sets”—groups of practices that “hang together” such that when providers report utilizing one, they are likely to report utilizing others within the same set—can advance the field by elucidating patterns of community-based psychosocial care being provided to autistic youth by an array of practitioners. Thus, we sought to identify transdisciplinary sets of practices that community-based providers report using to treat autistic youth, report mean use rates of provider-reported practices sets, and analyze provider-, setting- and client-level characteristics predicting utilization of practice sets with autistic youth.

Providers from behavioral disciplines self-reported utilizing the most strategies overall, followed by those from the “other” discipline, then allied health, medical, educational, and mental health professions. Lower educational attainment (<4-year degree) and low- to mid-range experience (0–10 years, 11–20 years) were associated with the most reported strategy use across all strategies. Providers working in two or more treatment settings (referred to as settings) reported greater overall use of strategies than those working in a single setting. Providers who reported sometimes working with autistic youth with co-occurring IDD endorsed the greatest variety of strategies utilized. Working with children from high SES backgrounds was associated with lower overall use of strategies, while no difference in average use of strategies was associated with working with youth from low SES backgrounds.

Our study provides the first large-scale, comprehensive evaluation of the landscape of self-reported practices utilized by community-based providers for autistic youth in community settings in the United States. Further, this study advances the field by identifying transdisciplinary practices commonly utilized together in community-based settings for autistic youth (see Table 2). Provider-, setting-, and client-level characteristics significantly predicted provider-reported use of strategies and specific practice sets. Importantly, these findings reflect the complexity, inconsistency, and confounding state of the landscape of treatment practices currently being delivered to autistic youth who experience social difficulties, externalizing behaviors, and/or anxiety (Table 5).

Overall, providers who reported being somewhat or very familiar with the practices reported using ABS (e.g., providing choices) most and TS (e.g., peer modeling) least often. This may be because it is easier to use ABS, such as embedding special interests in interactions and environmental structuring, than to teach skills using procedures such as shaping or chaining. Notably, CBTS were reported to be utilized only slightly more than TS. However, the number of providers who were able to provide use ratings for CBTS was much lower than TS due to limited familiarity of the discrete practices comprising the CBTS practice set (n = 119 versus 266, respectively). Additionally, patterns of provider-reported practice set use was more variable for child-level characteristics than provider- or setting-level characteristics. Providers who frequently delivered treatment to autistic youth with co-occurring IDD used behavioral strategies–CBS and ABS–more than other providers. This finding is consistent with existing literature; cognitive components of cognitive-behavioral therapy are often reduced or eliminated when delivered to children with IDD (45, 46) despite adapted CBT being found to reduce anxiety symptoms in this population (47). Further, high and low SES was variably related to provider-reported practice set use.

Overall, these results reflect the complex and confounding landscape of community-based services for autistic youth in the United States. Further, these results highlight the numerous provider-, setting-, and child-level factors that interact to impact the provider-reported use of these transdisciplinary practice sets within the existing autism system of care (58, 59). By taking this transdisciplinary, transtheoretical, content-agnostic study approach (e.g., broad provider eligibility, reduced practice jargon, etc.), we provide quantitative evidence to elucidate the complexity of autism service provision in the United States. We hope that stakeholders and affinity groups (e.g., researchers, educators, policymakers, special interest groups, practitioners, etc.) will utilize these results to identify areas of strength and improvement within the service system as well as proximal points of engagement and change with community partners, and develop or investigate the effectiveness of multi-level systemic interventions. Ultimately, my co-authors and I hope that these results will motivate dialogue, research, and action to make necessary changes to the system of care for autistic youth.

Systematic efforts must be made to both effectively disseminate evidence-based ASD practices (60) and facilitate practice use through implementation strategies within usual, community-based settings (61). Utilizing autism-specific evidence-based implementation toolkits within community-based agencies and schools serving autistic youth may assist with identifying ASD practices that are feasible and acceptable for use by providers with varied educational and training backgrounds and professional norms, fit within the service setting, and match the needs of the children and families (62–64). Moreover, implementation toolkits–especially those involving community-engaged approaches–may increase organizational and provider readiness for implementing the use of practices (65) and de-implementing unsupported or problematic practices, thereby increasing the quality of ASD community-based psychosocial services and improving the quality of life of autistic youth with co-occurring conditions.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

IRB approval was obtained from the following institutions: San Diego State University, Michigan State University, St. John’s University, Drexel University, Rush University, Stony Brook University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

AD contributed to study conceptualization, methodology, project multisite administration, recruitment, data collection, statistical analyses, and manuscript writing. AS contributed to statistical analysis and manuscript writing. LM, CK, LS, AW, EC, and ML contributed to study conceptualization, methodology, project administration, recruitment, data collection, results interpretation, and reviewing and editing of the manuscript. ML led conceptualization of statistical analyses within the manuscript. All authors contributed to the article and approved the submitted version.

This work was supported by the Adelphi University Center for Health Innovation, Pershing Charitable Trust, Brian Wright Memorial Autism Fund, and by funding through the National Institute of Mental Health (K01MH093477 [PI: Drahota] and R01MH110585 [PI: Lerner]), Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23HD087427 [PI: Kerns]), Michael Smith Foundation for Health Research Scholar Award (SCH-2021-1709 [PI: Kerns]), and Simons Foundation (SFARI #381283 [PI: Lerner]).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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