At pre-test, 30 participants represented behavioral health staff (13.33%, n = 4), nurse (6.67%, n = 2), nurse practitioner (13.33%, n = 4), physician (63.33%, n = 19), and medical support staff (3.33%, n = 1) (Table 1). Participants specialized in developmental and behavioral pediatrics (3.33%), family medicine (23.33%, n = 7), pediatrics (60%, n = 18), psychiatry (3.33%, n = 1), and other including clinical social work, med-peds, and trauma (10%, n = 3). Most participants (66.06%, n = 16) have between three to ten years of experience in practice.

Participants were assessed via a five-point Likert scale on self-reported ability related to autism screening, care management, and patient education (Table 2). Participants reported a significant increase in their perceived ability to administer level 1 autism screeners from 43.33% (n = 11) reporting above average ability or very able at pre-test compared to 52.94% (n = 15) at post-test (p = 0.0029). Participants reported a significant increase in their perceived ability to counsel families from 20% (n = 6) reporting average ability or very able at pre-test compared to 58.82% (n = 10) at post-test (p = 0.0065).

a. Sample of a Table footnote (Table footnote is dispensable).

The largest increase from pre-test to post-test was self-reported ability to manage treatment of autistic patients with 13.33% (n = 4) of participants reported having above average ability or very able at pre-test compared to 82.36% (n = 14) at post-test (p < 0.0001). In the subsample of participants that matched from pre-test to post-test (n = 9), there was a statistically significant increase in self-rated ability to counsel families about autism (pre-test mean = 3.00, post-test mean = 3.89, p = 0.0313) and manage autistic patients’ care (pre-test mean = 2.56, post-test mean = 4.11, p = 0.0078).

Participants expressed higher agreement with some self-efficacy statements at mid-point (n = 18) and more so at post-test (n = 17) compared to pre-test (n = 30), indicating increasing levels of confidence as the training progressed (Table 2). For example, more participants reported feeling confident about educating their patients about autism at post-test compared to pre-test. A majority of participants (70.59%, n = 12) strongly agreed at post-test that they felt confident educating patients about autism compared to 3.33% (n = 1) at pre-test (p = 0.0019). More than half (64.71%, n = 11) of participants also strongly agreed to feeling confident counseling patients on available treatments and realistic treatment expectations at post-test compared to 3.33% (n = 1) at pre-test (p = 0.0002).

Additionally, more participants reported feeling confident about caring for autistic patients at post-test compared to pre-test including feeling confident managing the primary care needs of autistic patients, feeling confident interpreting results of autism screening, and understanding the concerns of early intervention. Although there were increases in unmatched data, they were not statistically significant in the matched subsample (n = 9).

At post-test, participants reflected on how the training changed their practice and behaviors with many participants feeling confident in the processes, protocols, and workflows related to autism care of patients. For example, participants indicated feeling confident making referrals, observing behaviors, identifying children on the autism spectrum, and using the word “autism” in conversations. Many of these statements were further contextualized through the interviews and focus groups [30] .

Unmatched analyses indicated changes in clinicians’ reporting of feeling sensitive to others’ feelings/emotions, interest in talking with their patients, and connected with their patients and colleagues (Table 3). In matched analyses (n = 9), clinicians reported at pre-program versus post-program feeling more empathetic with their patients (2.11 and 1.22, respectively, p = 0.0156); feeling more empathetic with their colleagues (2.33 and 1.22, respectively, p = 0.0391); and being more sensitive to others’ feelings or emotions (2.11 and 1.22, respectively, p = 0.0313). There were found no statistically significant change in professional fulfillment in both matched and unmatched analyses.

Ten clinicians participated in the focus groups and nine completed the pre-focus group survey to assess professional characteristics of participants (i.e., role/title, medical specialty, years of experience, number of sessions attended). Participants represented physicians (44.44%, n = 4), nurse practitioners (44.44%, n = 4), administrative leadership (11.11%, n = 1), and specialties including pediatrics (77.78%, n = 7), psychiatry (11.11%, n = 1), and integrated behavior health (11.11%, n = 1). One-third (n = 3) of participants had 3 - 5 years of experience in practice and 55.55% (n = 5) had more than 10 years of experience. On average, participants attended ten out of 12 sessions. Themes that emerged from interviews and focus groups were organized according to NPT [27] constructs. We present key themes and illustrative quotes to highlight participant feedback and provide context to the surveys (Table 5).

Coherence occurs when participants make sense of a new practice, why it is important, and how it fits into their practice [27] . Participants were highly motivated to engage in BCAEP because they had a previously established interest in autism, and some had noticed increasing numbers of their patients presenting with symptoms of autism but needed enhanced skills to feel confident working with these patients. According to one participant who had “been in practice for 25 years”, they noticed an increase in autistic patients in their practice “and… I’m talking the ones that are so obvious” [30] .

Such increase in developmental services also highlights the importance of collaboration. Participants noted the importance of engaging in bidirectional knowledge transfer with their colleagues. This internal motivation served as the driving force behind participants’ reflection on how their individual roles in the clinic can support the autism screening and follow-up and how they could improve existing procedures or start implementing new ones. One participant shared paying more attention to “…signs we might want to be noticing… so, for me, this is about how do I take that information from the trainings and put it into some practice” [30] .

The construct cognitive participation [27] requires a focus on identifying the problem, working to solve the problem, and sustaining the work. Participants described components of their work that need to change in order to improve their individual practice as well as their clinic as a team. Participants reflected on their confidence regarding the extent to which they had the tools and expertise necessary to create change. For example, one participant “… did start doing CARS evaluations after the [BCAEP] started, partially because I just had more confidence…” [30] .

Participants fell into two categories: clinicians who were familiar with autism screening and those who were newer to the autism evaluations. Some had been using these tools for years while others just started to use the tools within their practice. For example, one participant had “trained in the CARS as a fellow, probably, you know, actually performed it with some small [number of patients], and then I was in the real-world practicing and using it…” [30] . Case discussions with other clinicians and presentations from knowledgeable leaders in the field during BCAEP provided participants who were newer to screening tools with more confidence.

The third step is collective action [27] , which refers to the action steps needed to implement new practices participants learned from BCAEP. For example, interacting with systems already in place (e.g., electronic medical record, special education system), barriers (e.g., COVID-19 pandemic, lack of services availability), and allocation of time, resources, and personnel responsibilities.

The biggest barriers were long wait times to get patients evaluated by a specialist and logistical complications resulting from the COVID-19 pandemic. Participants expressed wanting to expand these skills to PCCs to make evaluations more time-efficient and to ease the burden on the smaller group of individuals currently performing screenings. For example, dedicating “[even] four to six hours a week to just do… the screening diagnostic” had been helpful in getting patients seen by specialists more quickly [30] . Moreover, there needs to be infrastructure to support changes made to protocols within the clinic. For instance, one participant described the steps required to enter screening results into the electronic medical record, “We’re in kind of like a paper world. So, you get the paper screener… and then it’s put into the computer, or you can yourself put it in or have your medical assistant [or] whoever. Sometimes there are lags or drops in [that] process. I think the ultimate goal and what most clinics should be really doing in this day and age is… everything should… just [be inputted] directly into the computer….” [30] .

The process from screening, diagnosis, and services receipt involves many steps. It requires concrete systems of accountability and strong communication between everyone involved. One participant described that they “would love someone to walk [families] through this [Applied Behavior Analysis or ABA] process” because families may get “stuck at paperwork which is… the very beginning step” [30] .

Lastly, participants discussed collaborations with other clinicians. Since before the COVID-19 pandemic, there were “little cross collaboration there in pediatrics” [30] . During the pandemic, connection with other clinicians was even more important. One participant emphasized that it is “… important [for nurse practitioners to] stay connected... especially because we are going to continue to see increasing numbers of autistic children” [30] . Having a community could reduce feelings of isolation for clinicians. One participant reported that they “love[d] the fact that I could see into the thoughts and experiences of others… And to hear… what other practices are struggling with or doing well with. So that whole like community feel[ing], I thought was great” [30] .

Reflexive working is defined as participants’ assessment of the actions they took and whether they were useful or successfully implemented [27] . In the current evaluation, reflexive working applied to when participants evaluated 1) their implementation of strategies learned during the training, 2) training content, and 3) how training was delivered.

BCAEP was helpful in increasing rates of autism screening, which could catalyze referrals to specialists, thus reducing wait times. Access to external services such as ABA, however, remained scarce and could not be addressed by BCAEP alone. One participant reported that they were “continuing to have, unfortunately, a lot of trouble getting kids hooked in with ABA, and part of it is that [the insurance system] is claiming that I am not qualified to do autism evaluations...” [30] .

Additionally, participants noted the importance of effectively communicating with families, using transparent language. One participant “made a point of using the word [autism]… most parents were thinking it anyway, and if you don’t say it, then they continue to worry inside… they almost… appreciated hearing that” [30] .

Participants reported positive feedback about training delivery. Factors that increased training engagement included learning from other participants: “The process of [going] through a case presentation from another pediatrician at another health center about a tough diagnostic disclosure with a family with language and cultural and whatever barriers. Like that experience… I found the most valuable” [30] . Participants also offered additional topics for future trainings such as transition to adult services, ABA, and medications.