On Behalf of the Washington Autism Alliance, an organization that serves constituents throughout Washington State, we respectfully request that the ACGME Review Committee for Psychiatry establish a definitive requirement for educational instruction and practical clinical experience concerning the care of individuals living with Autism Spectrum Disorder and Intellectual and Developmental Disabilities (ASD/IDD). Our particular focus is on ensuring future practitioners are equipped to manage the psychiatric requirements of adults who have severe and profound forms of autism.

We urge you to consider the evidence detailed below:

1. ASD/IDD are Enduring Conditions, Not Limited to Childhood

• While current ACGME requirements for GME in Child and Adolescent Psychiatry stipulate that “Fellows must have an organized educational clinical experience in intellectual disability (intellectual development disorder) and other developmental disorders,”
• The ACGME requirements for General Medical Education in Psychiatry (adult training) contain no similar provision.

2. Autism Prevalence is High and Rising, Affecting a Growing Adult Population

• The most recent CDC data indicates a prevalence of 1 in 31 (3.2%) among 8-year-olds. Given the continuous yearly rise in birth year prevalence (approximately a 7% increase annually), the number of young people with autism transitioning into the adult care system is steadily increasing.
• Approximately 27% of those diagnosed with ASD meet the criteria for profound autism, which necessitates 24-hour, intensive, long-term adult support (Hughes et al. 2023).

3. Adults with ASD/IDD Experience Psychiatric Comorbidities at Elevated Rates

• The occurrence of conditions such as OCD, psychosis, and ADHD is 10 times greater in individuals with ASD compared to those without (Croen et al. 2015).
• Rates for self-injurious behaviors, depression, anxiety, and bipolar disorder are also substantially higher in the ASD population (Croen et al. 2015).

4. Education and Clinical Exposure to ASD/IDD in Adult Psychiatry Residency is Severely Insufficient

• A recent survey of adult general psychiatry program directors revealed that only a minority provide any formal educational instruction or clinical experiences in this area (Marrus et al. 2023).
• This deficit in residency training results in psychiatrists who lack the necessary confidence and expertise to manage individuals with the more severe manifestations of ASD/IDD.

5. Individuals with Profound/Severe Autism are Systematically Excluded from Clinical Research

• Clinical studies concerning autism have increasingly and systematically failed to include persons with profound/severe autism (Stedman et al. 2019).
• There is an urgent need for psychiatric clinical care for adults with ASD/IDD who exhibit challenging behaviors, particularly among those with profound/severe autism. This crucial care encompasses pharmaceutical interventions, behavioral strategies, and specialized neuromodulation treatments, such as electroconvulsive therapy for co-occurring catatonia.

6. Required Training in ASD/IDD Has Been Adopted by Canada Since 2020

Canada’s Royal College of Physicians currently mandates that general psychiatry residency include “Care of special populations (integrated into other experiences or as discrete experiences), including patients with … developmental disorders, including intellectual disability and autism spectrum disorder” (Psychiatry Training Experiences, 2020 Version 1.0).

We recommend that the committee institute the following revisions:

• The first proposal mirrors the existing child and adolescent psychiatry fellowship requirement but specifies adults; the second establishes a required adult clinical rotation:
  • Residents must have an organized educational clinical experience in intellectual disability (intellectual development disorder) and other developmental disorders in adults.
  • Resident experience in psychiatry must include one month FTE of organized clinical experience focused on the evaluation and clinical management of adult patients with autism spectrum disorder and intellectual development disorders that does not exclude patients with profound/severe autism.

• The explicit inclusion of the term “adults” is essential to ensure programs do not substitute training in child-focused autism clinics, as treating adults with ASD/IDD presents distinct challenges. The clause that prohibits the exclusion of profound/severe autism is vital because historical practices have demonstrated that this population is consistently marginalized.

The psychiatric needs of adults with ASD/IDD have been neglected for too long by the General Psychiatry field. These proposed modifications to the Graduate Medical Education in General Psychiatry program requirements offer a timely opportunity to educate and empower future psychiatrists to serve this adult patient demographic. These changes are also fully aligned with wider efforts to integrate disability-related competencies into medical education.

Thank you for your careful consideration of our recommendations.