Provider attitudes

TYPE Mini Review PUBLISHED 02 May 2024| DOI 10.3389/frcha.2024.1363532

EDITED BY

Marco Turi,

University of Salento, Italy

REVIEWED BY

Alessandra Gabellone,

University of Bari Aldo Moro, Italy

*CORRESPONDENCE

Elizabeth A. DeLucia

[email protected]

RECEIVED 30 December 2023

ACCEPTED 27 February 2024

PUBLISHED 02 May 2024

CITATION

DeLucia EA, Harden SM and Scarpa A (2024)

Provider attitudes toward evidence-based

practice in autism: a mini-review.

Front. Child Adolesc. Psychiatry 3:1363532.

doi: 10.3389/frcha.2024.1363532

COPYRIGHT

© 2024 DeLucia, Harden and Scarpa. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Frontiers in Child and Adolescent Psychiatry

Provider attitudes toward evidence-based practice in autism: a mini-review Elizabeth A. DeLucia1*, Samantha M. Harden2 and Angela Scarpa1

1Virginia Tech Autism Clinic & Center for Autism Research, Virginia Tech, Blacksburg, VA, United States, 2Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, VA, United States

There are many established evidence-based practices (EBPs) for autistic youth which facilitate wellbeing and skill development across a range of domains. However, individuals on the autism spectrum are consistently underserved in mental health settings, limiting their access to these EBPs. Positive provider attitudes toward EBPs may increase their uptake or use. The current mini-review seeks to synthesize the literature regarding attitudes toward EBPs among providers working with autistic youth across a variety of settings (i.e., school, early intervention, and general mental health). Fifteen quantitative studies were included. The majority of studies (n= 13, 87%) utilized the Evidence Based Practice Attitudes Scale (EBPAS) or a variation of this scale. Attitudes toward EBPs were primarily used as a correlate or covariate, although some studies reported descriptive statistics of provider attitudes. When available, the reported results suggest that attitudes toward EBPs are moderately positive at baseline, although they vary between provider types. Two studies (13%) examined change in attitudes toward EBPs and suggested that they may be responsive to intervention. However, findings were mixed as to whether attitudes toward EBPs are predictive of EBP use/uptake. Implications and future directions are discussed.

KEYWORDS

evidence-based practice, autism spectrum disorder, provider attitudes, implementation

science, dissemination and implementation, autism

1 Introduction

A variety of evidence-based practices (EBPs) have been established to improve

outcomes for autistic youth across domains such as mental health, communication,

interfering behaviors, adaptive behavior, and social skills (1). Despite the existence of

such EBPs, youth on the autism spectrum are continuously underserved in behavioral

health and educational settings. Autistic youth face significant barriers to evidence-

based healthcare at the provider, organizational, and systemic levels (2). As a result,

scholars in the field of autism research have made repeated calls to utilize dissemination

and implementation science (DIS) to integrate existing EBPs into settings such as

behavioral/mental health clinics, early intervention providers, and schools (3, 4).

While DIS often focuses on organizational level factors to increase uptake of EBPs,

some literature has identified individual provider characteristics that are likely to be

important to EBP implementation in autism, such as previous training and motivation

(5), buy-in and beliefs about own capabilities, and beliefs about program outcomes (6).

More work is needed to fully understand the role that provider characteristics may play

in adoption, implementation, and sustainment processes. However, both theory and

empirical evidence from related fields suggest that provider characteristics are likely to

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DeLucia et al. 10.3389/frcha.2024.1363532

play a role in the improved implementation of EBPs for autistic

individuals. The theory of planned behavior [TPB (7)] suggests

that individual attitudes, subjective norms, and perceived

behavioral control all influence individual intention to act, which

in turn influences individual behavior. Applied to DIS, the TPB

posits that attitudes toward EBPs should influence provider

intention to conduct EBPs, which in turn should influence a

provider’s behavior of implementing an evidence-based approach.

This theoretical frame appears to be supported by the general

literature regarding implementation of an innovation as well as the

mental health EBP literature. In the business literature, Frambach

and Schillewaert (8) identify that individual attitudes play a role in

the adoption of new innovative practices, and Candel and

Pennings (9) suggest that the affective component of attitudes is

predictive of choosing to implement innovations. In the mental

health literature, a study of providers found that attitudes toward

specific EBPs were correlated with the degree to which providers

used that practice (10). Attitudes toward EBPs are also associated

with uptake of components of mental health EBPs such as

consultation (11) and routine outcome assessment following a

training (12). Attitudes toward research, a closely related concept

to attitudes toward EBPs, are also predictive of self-reported EBP

use among mental health clinicians (13).

2 Research strategy

Despite a robust extant literature on the TPB and attitudes

toward EBPs in general, no work has synthesized the literature

regarding attitudes toward EBPs in providers working with

autistic youth. As such, the current review sought to describe

and integrate the literature regarding attitudes toward EBPs

among providers, including educators and behavioral or allied

health professionals, who work with autistic children and

adolescents. The aims of this mini-review are twofold: (1) To

characterize and synthesize attitudes toward EBPs among

providers who work with autistic youth and (2) to consider key

correlates, predictors, and/or outcomes related to EBP attitudes

for autism providers.

Studies were included in the current review if they (1) included

a measure of provider attitudes toward behavioral health EBPs; (2)

included a sample of educators, other school providers, behavioral

health providers, or allied health professionals (e.g., occupational

therapists), and (3) included a sample of providers working with

autistic individuals at least part of the time.

The databases PsycInfo and PubMed were searched in April

and May 2023 for terms related to autism, evidence-based

practice, attitudes/beliefs, and providers/clinicians/educators.

Search terms included: autism, autis*, ASD, autism spectrum

disorder, Asperger’s, PDD-NOS, attitudes, beliefs, perceptions,

opinions, evidence based practice, evidence-based practice, EBP,

evidence based treatment, EBT, evidence based, best practice,

evidence based intervention, EBI, clinician, teacher, therapist,

educator, and provider. Studies meeting the inclusion criteria

were retained for synthesis. The Covidence review software was

utilized to aid in organization of included studies (14). This

Frontiers in Child and Adolescent Psychiatry 02

search should not be considered exhaustive. Rather, results

are intended to provide a broad overview of the scope of the

existing literature in order to inform future research on the

topic. The search yielded 15 studies, which are included in

the current review.

3 Results

Refer to Table 1 for details of the following results (15–29).

3.1 Location and demographics

Seven studies (47%) took place in Australia while six (40%)

took place in the United States. One study each took place in

Bangladesh (7%) and the Netherlands (7%). Eleven studies

reported participant gender; all of these samples were

predominately female. Five studies reported participant race; 80%

of these included predominately white participants. Mean age

ranged from 30.5 (18) to 44.6 (27) among the six studies

that reported average age (six additional studies reported age

range breakdowns).

3.2 Setting/provider types

3,683 providers were participants in the research. Most of these

providers participated in studies which included both school and

behavioral health providers. 11% of participants were in studies

which only included providers in behavioral health and allied

health settings, and 21% of providers were in studies that

exclusively investigated school provider attitudes.

3.3 Measurement strategy

Most studies (87%) utilized the Evidence Based Practice

Attitudes Scale [EBPAS (30)] either in its original form (73%) or

an adaptation (13%; the EBPAS-36 or the Modified Practice

Attitudes Scale, MPAS). The EBPAS is a 15-item measure of

provider attitudes toward EBPs. It includes four subscales rated

on a scale of 0–4: Requirements (i.e., likelihood of using an EBP

if it was required by your organization); Appeal (i.e., likelihood

of using an EBP if it is intuitively appealing); Openness

(i.e., general open-mindedness to using an EBP) and Divergence

(i.e., amount that EBPs diverge or are different from your

current practices). The EBPAS-36 (31) is a 36-item form of the

measure, and the Modified Practice Attitudes Scale [MPAS (32)]

is an 8-item version. Paynter et al. (17) utilized the EBPAS as

well as the Attitude To Research Scale [ATR (33)]. The two

remaining studies used other questionnaire/survey measures,

including the Evidence Based Practice Innovation Survey

[EBPIAS (23)] which assesses factors involved in EBP decision

making among teachers, and a measure of EBP attitudes,

knowledge, and training (21, 34).

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TABLE 1 Included study characteristics and findings.

Study Title Location n Sample Measures Findings Paynter et al. (15)

Allied health professional’s knowledge and use of ASD intervention practices

Australia 156 Psychologists, BA, SLP, or OT EBPAS EBPAS requirements scale correlated negatively with amount of time working in autism field

Sam et al. (16) Employing evidence-based practices for children with autism in elementary schools

Southeastern US state

486 Elementary teachers (SPED, gen ed, admin, SLP)

EBPAS There was a Group × Time interaction for the appeal domain of the EBPAS, favoring group that received implementation intervention

Paynter et al. (17)

Brief report: Perceived evidence and use of autism intervention strategies in early intervention providers

Australia 71 EI providers including teachers, early childcare providers, and allied health professionals

EBPAS, ATR The EBPAS was not a significant predictor of intended future EBP use in regressions except for exercise/ movement; ATR was a significant predictor of intended future use

Pervin and Hagmayer (18)

Attitudes towards evidence-based practice of professionals working with children and adolescents with autism spectrum disorder in Bangladesh

Bangladesh 150 MH professionals or SPED teachers

EBPAS-36 Providers in Bangladesh reported overall moderately favorable attitudes toward EBP (mean score = 2.70/4.0)

Paynter et al. (19)

Utilisation of evidence-based practices by ASD early intervention service providers

Australia 72 EI providers including teachers, early childcare providers, and allied health professionals

EBPAS EBPAS requirement and openness scale correlated with knowledge of EBPs and likelihood of using EBP. Requirement subscale correlated with organizational culture variables

Verschuur et al. (20)

Pivotal response treatment: A study into the relationship between therapist characteristics and fidelity of implementation

Netherlands 41 PRT clinicians EBPAS EBPAS openness subscale correlated with PRT fidelity, appeal and total score did not

Cheung et al. (21)

The impact of workplace factors on evidence-based speech-language pathology practice for children with autism spectrum disorders

Australia 105 SLPs Bespoke survey Most providers viewed EBP as necessary, 41% reported a divide between research and practice, 66% reported that decisions in their workplace were in line with the research

Dyson et al. (22)

Therapists’ adaptations to an intervention to reduce challenging behaviors in children with autism spectrum disorder in publicly funded mental health services

Southern California, US

55 Therapists EBPAS Attitudes toward EBP did not predict adaptations made to services

Garrad et al. (23)

From research to reality: Australian evidence-based practice in autism education

Australia 151 Primary school teachers Evidence Based Practice Innovation Survey

Teachers made decisions to adopt or de-adopt an intervention based on several factors, especially student- centeredness

Stahmer and Aarons (24)

Attitudes toward adoption of evidence-based practices: A comparison of autism early intervention providers and children’s mental health providers

US 309 EI and child MH providers EBPAS EI providers had more favorable attitudes toward EBPs than MH providers

Paynter and Keen (25)

Knowledge and use of evidence-based practices by community-based early intervention service providers

Australia 99 EI providers including allied health professionals, behavior therapists, teachers, paraprofessionals, and managers

EBPAS EBPAS openness subscale correlated with EBP use and knowledge, other scales did not

Suhrheinrich et al. (26)

Practice-driven research for statewide scale up: Implementation outcomes of the California Autism Professional Training and Information Network

California, US 1543 Direct service providers and teachers

EBPAS Providers had moderately high scores on EBPAS openness, requirements, and appeal scales, with lower scores on the divergence scale. People who received EBP training had higher openness scores.

Aranbarri et al. (27)

Examining US Public Early Intervention for Toddlers With Autism: Characterizing Services and Readiness for Evidence-Based Practice Implementation

US 57 Early intervention providersa MPAS Scores did not differ between providers and coordinators, scores indicated moderate relationship between attitudes toward EBPs and EBP use. Provider EBP attitudes were correlated with organizational factors

Locke et al. (28)

Individual and organizational factors that affect implementation of evidence-based practices for children with autism in public schools: a cross- sectional observational study

Northeastern US

152 K-3 SPED teachers and staff EBPAS EBPAS divergence and appeal scales account for 10% of variance in DTT intensity. Openness and requirements scales not associated with any EBP use. No subscales were associated with PRT or visual schedule use

(Continued)

DeLucia et al. 10.3389/frcha.2024.1363532

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TABLE 1 Continued

Study Title Location n Sample Measures Findings Paynter et al. (29)

Attitudes towards and organizational support for evidence-based practices: A comparison of education and allied health professionals in autism

Australia 236 Allied health professionals and educators

EBPAS Attitudes were lower for allied health professionals compared to educators on EBPAS total score and appeal, openness, requirements subscales. Attitudes were correlated with organizational factors

ATR, attitudes to Research scale; BA, behavior analyst; DTT, discrete trial training; EBP, evidence-based practice; EBPAS, Evidence Based Practice Attitudes Scale; EI, early

intervention; MH, mental health; MPAS, Modified Practice Attitudes Scale; OT, occupational therapy; PRT, pivotal response treatment; SLP, speech language pathologist;

SPED, special education; US, United States. aStudy also included early intervention coordinators, administrator, and caregivers but they are not included in presented N.

DeLucia et al. 10.3389/frcha.2024.1363532

3.4 Overall attitudes toward EBPs

Most studies did not explicitly report descriptive statistics on EBP

attitudes and primarily reported provider attitudes as a covariate or

correlate of the likelihood of using EBPs (17, 19, 25), fidelity to EBPs

(20) or adaptations to EBPs (22). In studies that did report overall

EBP attitudes, attitudes were reported as moderately positive.

Average scores ranged from 2.99 to 3.32 out of 4 for all EBPAS

subscales except divergence reported in Suhrheinrich et al. (26) Also,

EBPAS average score was reported as 2.7 in Pervin andHagmayer (18).

3.5 Group differences in attitudes

Three studies (20%) compared EBP attitudes among provider

types. Two of these studies found significant group differences.

Autism early intervention providers had more positive EBP

attitudes than mental health clinicians working in the United

States (24). Additionally, in a study of 261 Australian educators

and allied health providers, allied health professionals

demonstrated less positive EBP attitudes than did educators (29).

In a comparison of early intervention providers and coordinators,

there were no group differences on attitudes toward EBPs (27).

3.6 Attitudes as a predictor of EBP use

Overall, findings were mixed with respect to the utility of EBP

attitudes as a predictor/correlate of outcomes. Several studies

identified an association between attitudes and EBP use/fidelity. For

example, in a study of early intervention providers in Australia, the

Requirement and Openness subscales of the EBPAS were correlated

with overall likelihood of using EBPs (19). Another study from the

same research team found that in a sample of 99 early intervention

providers, the Openness subscale was associated with EBP use and

knowledge, while other EBPAS scales did not correlate with EBP use

(25). Paynter et al. also investigated the EBPAS’s predictive value for

the use of several specific EBPs among early intervention clinicians;

they found that the EBPAS predicted future use of exercise, an EBP

for autistic youth, but did not predict the future use of other EBPs

(17). A study of 153 K-3 special education teachers and staff in the

northeastern United States found that the Divergence and Appeal

subscales of the EBPAS accounted for 10% of the variance in use of

discrete trial training (28).

Frontiers in Child and Adolescent Psychiatry 04

On the other hand, several studies also presented null findings

with respect to the association between attitudes and EBP use.

Dyson et al. (22) found no association between EBP attitudes and

the likelihood of making adaptations to an EBP for autistic youth.

Although Locke et al. (28) found a positive association between EBP

attitudes and discrete trial training, they noted that there was no

association between the EBPAS and use of two other autism EBPs

(pivotal response treatment and visual schedules). Furthermore, for

many of the studies discussed, particular subscales/components of

EBP attitudes were most associated with outcomes, rather than an

association between outcomes and a provider’s overall EBP attitudes.

3.7 Altering attitudes toward EBPs

Two studies investigated whether intervention could change

individual provider attitudes toward EBPs. These interventions

included approaches such as training, goal setting, and coaching/

feedback, and attitudes toward EBPs improved when these DIS

interventions were implemented. For example, Sam et al. (16)

conducted a study in which schools were assigned to a

professional development model called the National Professional

Development Center (NPDC) or to services as usual. Schools in

the NPDC condition used a four-part process which included

focus on overall classroom quality, designation of measurable

student goals, matching student goals with appropriate EBPs, and

coaching/feedback. The authors found a group by time interaction

effect on the appeal domain of the EBPAS, such that attitudes

toward intuitively appealing EBPs improved from pre-test to post-

test, only for the NPDC condition. Another study investigated

EBP attitudes in providers who had vs. had not participated in the

California Autism Professional Training and Implementation

Network [CAPTAIN (26)]. CAPTAIN is a network designed to

develop dissemination plans and provide training on EBPs

throughout California. Results indicated that individuals who had

attended CAPTAIN training displayed higher levels of Openness

on the EBPAS, indicating more willingness to implement EBPs

into their practice, relative to the control group.

4 Discussion

The included studies suggest a mixed literature regarding

autism provider attitudes toward EBPs. However, they provide

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DeLucia et al. 10.3389/frcha.2024.1363532

some evidence for the importance of attitudes as an

implementation factor, consistent with both the TPB and

existing DIS frameworks. Overall, the reviewed literature

suggests that autism providers have moderately positive

attitudes toward EBPs, although there is room for improving

attitudes. Interestingly, the vast majority (87%) of included

studies used a version of the EBPAS to measure attitudes.

Future psychometric research would do well to evaluate the use

of this measure specifically with autism providers, to better

understand how the measure applies for this population.

Additionally, there is some evidence that attitudes toward EBPs

are malleable in the two studies that examined interventions,

with improved attitudes after DIS strategies including feedback,

training, and goal setting (16, 26). This finding is encouraging,

as it suggests that there is potential for modifying EBP attitudes

through intervention.

Another important question to consider, then, is whether

attitudes are a meaningful construct in terms of predicting EBP

use/fidelity in providers working with autistic youth. DIS

researchers identify intervention acceptability and

appropriateness, concepts closely related to attitudes, as key

implementation outcomes (35–37), suggesting their importance

in implementation success. Within the autism literature

specifically, qualitative research has suggested that providers

perceive EBP attitudes (at the provider and leadership level) as

important in influencing implementation (38). Several studies in

the current review supported this idea, finding that EBP attitudes

are correlated with EBP use (17, 19, 25, 28), and one study

identified an association between EBP attitudes and

implementation fidelity (20). Yet, other studies found no

association between attitudes and EBP use (17, 22, 28). There

was considerable variability in the settings and types of autism

providers involved in the studies, which could explain the range

of findings. Overall, the present review highlights that while EBP

attitudes have promise as a predictor of implementation

outcomes, there is an overall lack of consensus in the literature

regarding the impact of provider EBP attitudes. While the wider

literature has established that leadership and organizational

factors are key to implementing EBPs in autism practice (38–40),

this review underscores the need for further research to clarify

the mixed landscape regarding individual provider attitudes

toward EBPs.

It is also important to consider the variety of practices which

fall under the EBP umbrella in the autism literature. DIS has

firmly established the importance of contextual factors when

implementing interventions (41–44), and a wide range of

contexts are at play in autism intervention due to the

interdisciplinary nature of autism services. In recent years, the

COVID-19 pandemic has resulted in a shift to telehealth services

for many health professionals, including those who work with

autistic individuals (45–47). The impact of this contextual factor

on providers’ attitudes toward EBPs is not well understood, and

future research should investigate this further. Gabellone et al.

(46) developed a questionnaire examining provider attitudes

toward using telehealth with autistic patients; this measure may

Frontiers in Child and Adolescent Psychiatry 05

provide a useful starting point to consider provider attitudes

toward conducting EBPs over telehealth.

Additionally, attitudes toward EBPs as a broad construct may

be significantly different than attitudes toward an individual EBP.

The clearest example of this possibility is applied behavioral

analysis (ABA), an umbrella term which can encompass a range

of autism EBPs. ABA has been subject to increasing scrutiny

over the last decade, with many autistic individuals arguing that

the outcomes ABA seeks to create are akin to “normalization” of

autistic people and do not target factors that are most important

to autistic individuals themselves (48). This perspective highlights

an important consideration within the context of the current

review: there is substantial heterogeneity in the outcomes

targeted in autism EBPs. Such variability highlights the

importance of using participatory designs that consider autistic

perspectives when conducting future research on attitudes toward

and use of EBPs.

4.1 Implications for implementation science

The present review has implications for implementation

science in general and within the autism field. Given the

emerging evidence provided here for malleability of attitudes,

it is recommended that implementation scientists consider

implementation strategies, such as those identified by Powell

et al. (49) (e.g., educational outreach, local consensus

discussions, providing ongoing consultation) with the explicit

goal of altering attitudes toward EBPs in general and toward

specific EBPs. This work can subsequently measure

downstream effects on adoption decisions, implementation,

and sustainment. If effective, using DIS strategies to alter

attitudes may serve to decrease translational lag time and

ultimately improve access to services.

The process of changing attitudes should be done in

collaboration with the community, preferably through

participatory research (50, 51). In addition to including autistic

individuals in research partnerships, it may also be beneficial to

include caregivers for autistic people, given that many EBPs

include a family-mediated approach (1). Models such as the

integrated research-practice partnership process model (52) may

aid in this approach. In addition, applying a health equity lens to

existing frameworks, as described by Fort et al. (53) may prove

important particularly for historically underserved populations.

When considering attitudes, it is critically important for

implementation scientists to consider the role and perception of

researchers by the community. Partnering with community

groups is therefore a necessary step. As such, the implementation

strategy of identifying champions (46) may prove useful,

particularly if attitudes are to be targeted.

It is further recommended that implementation scientists also

consider provider attitudes toward a specific EBP to determine

whether modifying attitudes toward a particular approach

changes uptake. General mental health literature suggests that

EBP attitudes can vary by EBP type (10). In the short term,

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DeLucia et al. 10.3389/frcha.2024.1363532

implementation scientists should consider measuring both

attitudes toward EBPs broadly as well as attitudes toward a

specific EBP, in order to clarify the role that attitudes toward

EBPs broadly and attitudes toward specific practices play in the

implementation process [e.g., Kemp et al. (54)].

5 Conclusion

The current review offers a synthesis of existing literature

regarding attitudes to EBPs among autism providers and suggests

several future research directions. Overall, EBPs are generally

viewed favorably, though attitudes may differ by provider type,

and the research is mixed on whether EBP attitudes impact

uptake by autism providers. Future implementation science,

ideally with participatory research designs, should continue to

consider autism provider EBP attitudes and the factors that

influence their impact on EBP use with autistic youth.

Author contributions

ED: Conceptualization, Writing – original draft, Writing –

review & editing. SH: Supervision, Writing – review & editing.

AS: Supervision, Writing – review & editing.

Frontiers in Child and Adolescent Psychiatry 06

Funding

The author(s) declare that financial support was received for

the research, authorship, and/or publication of this article.

Open access publication of this article was supported by the

Virginia Tech Center for Autism Research and the Virginia Tech

Department of Human Nutrition, Foods, and Exercise.

Conflict of interest

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.

Publisher’s note

All claims expressed in this article are solely those of the

authors and do not necessarily represent those of their affiliated

organizations, or those of the publisher, the editors and the

reviewers. Any product that may be evaluated in this article, or

claim that may be made by its manufacturer, is not guaranteed

or endorsed by the publisher.

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