Racial and ethnic disparities in quality of health care among children with autism and other developmental disabilities

Are the diagnostic rates of autistic females increasing? An examination of state-wide trends

BACKGROUND

Autism has been considered a 'male-dominant' condition. However, recent research suggests that autistic females are underdiagnosed, misdiagnosed, and later diagnosed. Females may also have different and more nuanced behavioral profiles. To examine diagnosis rates of females, we used 20 years of state-wide data to characterize historical trends in the diagnosis of autism in females to determine whether the proportion of females diagnosed with autism has changed over time.

METHODS

Data were drawn from 10,247 participants (males = 8,319, females = 1928) who received an autism diagnosis between 2000 and 2021 from state-wide autism centers associated with the University of North Carolina TEACCH Autism Program.

RESULTS

The rates of females diagnosed with autism increased at a greater rate compared with males. Age of diagnosis remained consistently higher for females. Late diagnosis (defined as 13+) increased over time across both males and females, however, was more commonly associated with females, particularly those with co-occurring intellectual disability.

CONCLUSIONS

Our results indicate that the proportion of females diagnosed with autism has increased steadily over a 20-year period, which likely reflects greater societal knowledge of how autism may manifest differentially in females.

Reducing Depressive Symptoms Among Latina Mothers of Autistic Children: A Randomized Controlled Trial

This study examines the intervention effect of a culturally tailored parent education program in reducing depressive symptoms among Latina mothers of autistic children. In this two-site randomized waitlist-control study (n = 109 mother-child dyads), a peer-to-peer mentoring (promotora) model was used to deliver an intervention that was designed to increase mothers' self-efficacy and use of evidence-based strategies. We assessed mothers' depressive symptom (CES-D) scores at three time points and used linear mixed models to determine whether their scores significantly changed from baseline to postintervention (Time 2) and at 4 months postintervention (Time 3). Results show that mothers in the intervention group reported a significant decrease in mean depressive symptom scores at Time 2 and that the effect was maintained at Time 3 with intermediate to medium effect sizes. There were no differences in results across sites. Findings suggest that Parents Taking Action, a culturally tailored intervention led by peer mentors, showed a significant effect both immediately after the intervention and 4 months postintervention in reducing depressive symptoms among Latina mothers of autistic children.

Race and Ethnicity Reporting in Occupational Therapy Research Among Autistic Youth

Historically marginalized racial and ethnic groups are underrepresented in autism research broadly; however, patterns of inclusion in occupational therapy research are unknown.In this secondary data analysis, we examined race and ethnicity reporting across articles included in a systematic review of evidence related to occupational therapy practice with autistic individuals <18 years (2013-2021).Two team members reached >90% interrater coding agreement in race and ethnicity reporting across articles in ADLs/IADLs, education/work, play, sleep, and social participation in clinics, homes/communities, and schools.Intervention outcomes of ADL/IADLs (66.7%) and play (66.7%) had low rates of reporting, while social participation in schools (100%) and education/work (100%) had higher rates of reporting. Sample diversity was greatest among research in schools and most limited in clinic-based settings.Systemic racism that limits individuals' participation in occupational therapy research perpetuates racial and ethnic health inequities among autistic children and adolescents.

Racial Disparities in Hospitalization Due to Ambulatory Care Sensitive Conditions Among U.S. Children with Autism

PURPOSE

This study was to investigate the factors associated with preventable hospitalization due to ambulatory care sensitive conditions (ACSCs) in children with autism.

METHODS

Using secondary data from the U.S. Nationwide Inpatient Sample (NIS), multivariable regression analyses were conducted to determine the potential effect of race and income level on the likelihood of inpatient stays for ACSCs among autistic children. Pediatric ACSCs included three acute conditions (dehydration, gastroenteritis, and urinary infection) and three chronic conditions (asthma, constipation, and diabetes short-term complications).

RESULTS

In this analysis, there were 21,733 hospitalizations among children with autism; about 10% were hospitalized due to pediatric ACSCs. Overall, the odds of ACSCs hospitalization were greater among Hispanic and Black autistic children versus White autistic children. Both Hispanic and Black autistic children from the lowest income level had the highest odds to be hospitalized for chronic ACSCs.

CONCLUSION

Inequities of access to health care among racial/ethnic minorities were most notable for autistic children with chronic ACSC conditions.

A Systematic Review of Recruiting and Retaining Sociodemographically Diverse Families in Neurodevelopmental Research Studies

Underrepresentation of socioeconomically, culturally, and/or linguistically diverse (SCLD) children with neurodevelopmental disorders (NDD) and their families has become a focal point for researchers. This systematic review aimed to identify researchers' strategies for recruiting and retaining SCLD families of children with NDD, published between 1993 and 2018. One hundred twenty-six articles were included, and study samples were categorized as "High SCLD" and "Low SCLD". Chi-square tests of independence were used to determine associations between sample composition (i.e., High/Low SCLD sample) and study characteristics reported. Significant associations were found between sample composition and studies that explicitly stated intention to recruit SCLD families, χ2(1) = 12.70, p < .001, Phi = 0.38 (moderate); and for studies that reported the following participant characteristics: language, χ2(1) = 29.58, p < .001, Phi = 0.48 (moderate-to-large); and race/ethnicity + SES + language, χ2(1) = 19.26, p <. 001, Phi = 0.39 (moderate). However, associations were not found between recruitment and retention approaches and whether studies included High SCLD or Low SCLD samples. Further study of NDD researchers' recruitment and retention approaches that successfully include SCLD families is needed.

Unpacking the prevalence: A warning against overstating the recently narrowed gap for Black autistic youth

Recent findings from the Centers for Disease Control and Prevention's (CDC) Autism and Developmental Disabilities Monitoring (ADDM) Network's 2020 prevalence report indicate that disparities in autism diagnoses between Black and White youth have narrowed, reflecting improved screening, awareness, and access to services (Maenner et al., 2023. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 72, 1-14.). Claims of reducing disparities beyond prevalence rates, however, are not fully supported, as indicated by the reality that Black youth whose screenings indicate autistic traits are still not being referred for full evaluation or early intervention services at the same rate as their White peers (Major et al., 2020. Autism, 24, 1629-1638; Smith et al., 2020. Pediatrics, 145, S35-S46.). Black 8-year-olds identified as autistic still experience disparate educational placements (Waitoller et al., 2010. The Journal of Special Education. 44, 29-49.) where services may not be autism-specific or have Individual Education Plan goals only focused on "behavior problems" (Severini et al., 2018. Journal of Autism and Developmental Disorders, 48, 3261-3272.), are served in the most restrictive environments (Skiba et al., 2006. Exceptional Children, 72, 411-424.) and lack consistent augmentative and alternative communication support (Pope et al., 2022. American Journal of Speech-Language Pathology, 31, 2159-2174.). Additionally, ADMM researchers report consistent disparities in the identification of co-occurring intellectual disability where Black autistic children have significantly more co-occurrences than White autistic children. The purpose of this commentary is to first examine the assertion that the narrowed gap indicates, "…improved…access to services among historically underserved groups," (p. 9) (Maenner et al., 2023. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 72, 1-14.). We will then recommend strategies to address the ongoing disparities.

Differential Performance of Social Communication Questionnaire Items in African American/Black vs. White Children

Screening for autism spectrum disorder (ASD) is an essential early step in the identification process and inaccurate screening may lead to significant delays in the onset of treatment. Past research has highlighted discrepancies in the performance of ASD screening tools such as the Social Communication Questionnaire (SCQ) among certain racial and ethnic groups. The current study explored the functioning of the SCQ among African American/Black and White respondents based on item level performance on the measure. Differential Item Functioning (DIF) analyses showed that 16 (41%) items of the SCQ functioned differently for African American/Black respondents when compared to White respondents. Implications, such as the potential for delayed diagnosis and treatment, and the influence on downstream outcomes, are discussed.

Demographic differences in access to health/therapeutic services over first year of the pandemic: a SPARK COVID-19 impact survey analysis

Introduction

This analysis examined changes in services received and service recovery one-year post-pandemic compared to pre-pandemic levels in children with ASD aged between 19 months and 17 years in various subgroups based on factors such as age, income, race/ethnicity, geographic location, and sex.

Methods

An online, parent report survey was completed by the parents of children with ASD in the SPARK study cohort (N = 6,393). Descriptive statistics, chi-square analyses, and Spearman correlations were performed to study associations between various factors and service access, pre-pandemic and one-year, post-pandemic.

Results

One year after pandemic, the lag in service recovery in children with ASD was greatest for PT/OT services followed by SLT. ABA services only recovered in half of the subgroups. In contrast, SES fully recovered and MH and MED services superseded pre-pandemic levels. Across majority of the timepoints, younger children received more SLT, PT/OT, and ABA services whereas older children received more SES, MH, and MED services. Higher income families accessed more SES, SLT, and ABA whereas lower income families received more MH services. White families received less SLT compared to non-white families. Hispanic families received more SLT services compared to non-Hispanic families. Compared to rural families, urban families received more ABA services at baseline which also recovered one year after the pandemic. Certain counterintuitive findings may be attributed to home/remote schooling leading to reduced access to related services.

Conclusions

Future research and policy changes are needed to address the American healthcare vulnerabilities when serving children with ASD by enhancing the diversity of healthcare formats for continued service access during future pandemics and other similar crises.

Parental strategies to promote theory of mind development in autistic children of color

Introduction

Autism Spectrum Disorder is characterized by an impaired ability to take other people's perspectives, which is known as theory of mind. However, little is known about how theory of mind exhibits itself in autistic children of color and how parents foster their child's developmental skills in communities of color.

Methods

Two interviews were created to assess how parents appraise their child's developmental skills and help their child grow: a perspective-teaching interview and a general developmental skills interview. Four families participated in the study; three children were African American or mixed, while one had an Asian mother. Parents were asked how their child exhibited various developmental skills and how they helped their child with those milestones.

Results

Parents pointed at similar delays in theory of mind and other developmental skills, such as turn-taking and reading faces. They also provided similar strategies to teach those abilities, such as modeling and reinforcements. Several insights and common themes were found regarding autistic behaviors their children expressed and how those affected their parenting experiences.

Discussion

These findings allow for a better understanding of parents' experiences raising autistic children of color; future research could expand on their stories and create interventions tailored to these underrepresented communities.

Exploring the Perspectives of Parents of Individuals with Autism from Low-Resourced Communities to Inform Family Navigator Programs

Family navigator programs (i.e., programs to train family navigators) are becoming increasingly common among families of children with autism. Family navigators (i.e., individuals who help families access evaluations and/or services) may be parents of children with autism themselves or health professionals. Extant research has shown that family navigators can help families receive timely diagnostic evaluations and initial services. Yet, the development of family navigator programs is unclear; by exploring the input of families of children with autism, such programs can be responsive to family needs. In this study, we extend the extent literature by exploring the lived experiences of 12 parents of autistic children from low-resourced communities to inform the development of a family navigator program. Findings demonstrated that navigator programs need to prepare navigators to address barriers such as limited knowledge and difficulty accepting an autism diagnosis. Navigator programs should teach navigators to use strategies with families including educating families about services and connecting families with peer support. Program content should reflect direct services, government services, and advocacy strategies. Notably, for true improvements to service access for all autistic children, systemic changes are also needed in the service delivery systems. Implications are discussed.

Comparative effects of mindfulness-based stress reduction and psychoeducational support on parenting stress in families of autistic preschoolers

LAY ABSTRACT

Parents of autistic children often experience high levels of parenting stress, which can have negative mental and physical effects on both the parent and child. This study tested the efficacy of mindfulness-based stress reduction in reducing parenting stress in parents of preschool-aged autistic children compared to a psychoeducation and support intervention. We assessed parenting stress before and after the interventions and at 6- and 12-month follow-up. Both interventions significantly decreased parenting stress, but mindfulness-based stress reduction reduced stress more than did psychoeducation and support, with the strongest effect observed 1 year later. This suggests that the stress-reducing benefits of mindfulness-based stress reduction persist and may increase over time.

Exploring Latine Parent Leaders' and a Program Coordinator's Lived Experiences with a Culturally Adapted Parent-Directed Training Program

The purpose of the current study was to explore the lived experiences among parent leaders and a program coordinator who participated in a parent-directed training program to support other Latine parents of children with autism spectrum disorder. We used qualitative methods to explore 4 Latine parent leaders' and 1 program coordinator's experiences with a parent-directed training program to support other Latine parents who have children with autism spectrum disorder. We interviewed parent leaders and a program coordinator to learn about their lived experiences as leaders in a parent-directed training program. The following themes emerged from Interpretative Phenomenological Analysis data analysis: (a) personal growth, (b) leadership development, (c) sense of connection and community, (d) contributing to a larger and meaningful purpose, and (e) applying knowledge and skills to help other parents. A culturally adapted parent-directed training program has the potential to positively influence Latine parent leaders who are prepared to support parents of children with ASD. There were positive program impacts on parent leaders regarding personal growth, leadership development, connection and community, contribution to a larger purpose, and use of knowledge and skills to help other parents. We also discovered the importance of building a safe community for Latine parent leaders and other parents who have children with ASD in a parent-directed training program.

Digitally Diagnosing Multiple Developmental Delays Using Crowdsourcing Fused With Machine Learning: Protocol for a Human-in-the-Loop Machine Learning Study

BACKGROUND

A considerable number of minors in the United States are diagnosed with developmental or psychiatric conditions, potentially influenced by underdiagnosis factors such as cost, distance, and clinician availability. Despite the potential of digital phenotyping tools with machine learning (ML) approaches to expedite diagnoses and enhance diagnostic services for pediatric psychiatric conditions, existing methods face limitations because they use a limited set of social features for prediction tasks and focus on a single binary prediction, resulting in uncertain accuracies.

OBJECTIVE

This study aims to propose the development of a gamified web system for data collection, followed by a fusion of novel crowdsourcing algorithms with ML behavioral feature extraction approaches to simultaneously predict diagnoses of autism spectrum disorder and attention-deficit/hyperactivity disorder in a precise and specific manner.

METHODS

The proposed pipeline will consist of (1) gamified web applications to curate videos of social interactions adaptively based on the needs of the diagnostic system, (2) behavioral feature extraction techniques consisting of automated ML methods and novel crowdsourcing algorithms, and (3) the development of ML models that classify several conditions simultaneously and that adaptively request additional information based on uncertainties about the data.

RESULTS

A preliminary version of the web interface has been implemented, and a prior feature selection method has highlighted a core set of behavioral features that can be targeted through the proposed gamified approach.

CONCLUSIONS

The prospect for high reward stems from the possibility of creating the first artificial intelligence-powered tool that can identify complex social behaviors well enough to distinguish conditions with nuanced differentiators such as autism spectrum disorder and attention-deficit/hyperactivity disorder.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52205.

Barriers to Healthcare for Latinx Autistic Children and Adolescents

PURPOSE

To understand the ways in which autistic Latinx children experience disparities in diagnosis, healthcare, and receipt of specialty services.

METHODS

417 individuals who identified as Latinx caregivers of autistic children who were members of the same integrated healthcare system in Northern California were surveyed. Responses were analyzed using the child's insurance coverage (Government or Commercial) and caregiver's primary language (Spanish or English).

RESULTS

Compared to the commercially-insured, government-insured participants accessed several services at a higher rate and were less likely to cite the high cost of co-pays as a barrier.

CONCLUSION

There were no significant differences in service access by language status, but Spanish speakers were more likely to cite health literacy as a barrier to receiving care.

Validity of the Toddler Autism Symptom Inventory in Non-Hispanic White and Black Toddlers

Racial disparities exist in autism diagnosis, and yet, the development of most diagnostic tools has not explicitly examined measurement equity between racial and ethnic groups. We examined the validity of the Toddler Autism Symptom Inventory (TASI), a semi-structured interview developed for diagnosis of toddlers, in non-Hispanic Black/African American and non-Hispanic White children. After controlling for group differences in socio-economic status, no differences in diagnosis, age at diagnosis, mean developmental level, or autism severity were found. TASI ROC curves for both groups, in the overall sample, and in samples stratified by SES, showed high AUC values. Validity of two cutoff scores was acceptable. Lack of significant differences in TASI score or responses to individual items suggests similar symptomatology. These results provide early support for the use of the TASI in diagnostic evaluations of Black and White children.

Sociodemographic Disparities in Ambulatory Pediatric Telemedicine Utilization During COVID-19

Objective: Few studies have examined sociodemographic disparities in ambulatory pediatric telemedicine utilization during the coronavirus disease 2019 pandemic. We aimed to (1) assess disparities in telemedicine visit completion during the first 6 weeks of the pandemic in 2020 and (2) determine if these disparities were significantly different from those present in 2019, when all visits occurred in person. Methods: We compared sociodemographic characteristics of patients with successful versus unsuccessful telemedicine visits from March 10, 2020 to April 18, 2020, using generalized linear mixed models. We performed the same analysis for in-person visits from the same period in 2019. We tested for differences across years using interaction terms in a combined 2019-2020 model. Results: Of 3,639 telemedicine visits scheduled, 3,033 (83.3%) were successful. In 2020, Black/African American race was significantly associated with lower odds of telemedicine visit success (odds ratio 0.65 [95% confidence interval 0.49-0.87]) compared with White race, after adjusting for age, gender, ethnicity, insurance type, visit timing, visit specialty, social vulnerability index, and internet access. In 2019, racial identity other than White was significantly associated with lower odds of in-person visit success than White, as was public insurance compared with private. In the full 2019-2020 model, in-person visits (2019) had lower odds of success than telemedicine visits (2020), and neither race, insurance type, nor any other sociodemographic characteristic had significant interactions with year. Conclusions: Racial disparities were evident in telemedicine utilization early in the pandemic; however, these disparities were not significantly different from those seen in 2019, when all visits were in person. Furthermore, telemedicine may improve access to care overall, despite having no significant impact on inequity. Efforts to eliminate racial disparities in ambulatory pediatric health care utilization are necessary across visit modalities.

"It starts with a knock on the door": Caregiver and provider perspectives on healthcare communication for youth with intellectual and developmental disabilities

OBJECTIVES

Effective healthcare communication (HCC) is critical for youth with intellectual and developmental disabilities (IDD) who may have complex healthcare needs. The goal of this study was to gain family caregiver and provider perspectives on facilitators and challenges to effective HCC for youth with IDD.

METHODS

Caregivers of, and providers for youth with IDD were recruited from the community to participate in virtual focus group (FG) sessions. FGs were 60-90 min long and were facilitated by a research team consisting of caregivers and providers. The FGs were recorded, transcribed, and coded inductively for HCC themes.

RESULTS

Nineteen stakeholders participated in the FGs (caregivers: n = 14; providers: n = 5). Twenty-three themes were coded from the transcripts and were categorized by whether they focused on providers, caregivers, or healthcare systems.

CONCLUSIONS

Provider behaviors such as active listening and demonstrating humility were found to be critical for effective HCC. Fewer caregiver factors, such as advocacy, and systems factors such as visit format, emerged from the FG data. FG themes represent challenges that future interventions must address.

PRACTICE IMPLICATIONS

Efforts to improve HCC, and thus healthcare outcomes for youth with IDD, should address challenges identified by caregivers and providers.

Culture and Language Inclusion in the Practice of Applied Behavior Analysis: Next Steps for Improving Outcomes for Autistic Clients

As applied behavior analysis (ABA) is widely prescribed as an intervention for autistic children, ABA practitioners must have a thorough understanding of the impact of language and culture on the individuals and families they serve. The twin purposes of this article are to discuss cultural humility in ASD service delivery, and to provide an overview of practice parameters for the expansion of equity and inclusion. These efforts are guided by the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Readers will be provided with recommendations for incorporating culturally and linguistically appropriate services into training, practice, and supervision in ABA settings.

Patterns of Mental Health Service Use During the Transition to Adulthood Among Autistic Adolescents and Young Adults

Background

The time of transition into adulthood, especially when leaving school, is a time when many autistic adolescents and young adults (AYA) may stop receiving mental health services that they have relied on, leading to worse mental health outcomes. The purpose of this study was to describe patterns of mental health service use during transition to adulthood among autistic AYAs.

Methods

We performed a cross-sectional study using electronic health records from years 2015 to 2019 from one large university health care system. We included autistic individuals ages 11-27 with at least one clinical encounter annually in the cohort. Outcomes included psychotropic medications and psychotherapy received, psychotropic polypharmacy, psychiatric emergency department (ED) visits, and adverse drug events.

Results

Almost half of the 529 patients in the cohort received polypharmacy. The most common treatment was medication only (56.9%), followed by no treatment (22.7%), medication plus psychotherapy (18.7%), and psychotherapy only (data masked). The 17-21 age group had the highest odds of a psychiatric ED visit, whereas the 22-27 age group had the highest odds of receiving psychotropic medications and polypharmacy. Black AYA were more likely to receive psychotherapy and less likely to receive psychotropic polypharmacy than non-Hispanic Whites.

Conclusion

Autistic individuals may benefit from more support from the health care system for their transition into adulthood to maintain use of beneficial mental health services as they leave school and to reduce the frequency of adverse outcomes. Access to providers experienced treating the complex needs of autistic individuals is important to reduce disparities.

Pediatricians' role in healthcare for Latino autistic children: Shared decision-making versus "You've got to do everything on your own"

LAY ABSTRACT

Latino parents may choose to use complementary health approaches, such as vitamins, supplements, and special diets, for their autistic children. However, they might not tell their pediatrician about their complementary health approach use if they worry that the pediatrician will disapprove or judge them. This fear, along with pediatricians' lack of autism knowledge, creates barriers to "shared decision-making" between parents and pediatricians. Shared decision-making is a process where families and healthcare providers collaborate and exchange information in order to come to an agreement about treatment options. In our qualitative study with 12 bilingual Latino families of autistic children, we interviewed and observed families to learn about their experiences with both conventional healthcare (their pediatrician) and complementary health approaches. Our study results describe the parents' different pathways to an autism assessment, a process that is sometimes called the "diagnostic odyssey." The parents reported that conventional healthcare met their needs for their child's physical health but not for their child's developmental challenges. The parents who used complementary health approaches for their autistic children were more frustrated about a lack of autism information from pediatricians than those who did not use complementary health approaches. Finally, we describe two examples of successful shared decision-making between parents and pediatricians. We conclude that pediatricians who are able to talk about complementary health approaches with Latino families may help to facilitate shared decision-making and reduce healthcare disparities for Latino autistic children.

Barriers to service and unmet need among autistic adolescents and young adults

LAY ABSTRACT

Prior studies have described the roadblocks, or barriers, to needed services experienced by families with young autistic children, but less research has focused on those faced by autistic adolescents and young adults. In this study, we wished to understand the barriers to service experienced by autistic adolescents and young adults and their families. We surveyed 174 caregivers of autistic youth between 16 to 30 years old. We found that caregivers who felt more caregiving burden had more difficulty accessing services for their youth. Specifically, caregivers who felt more strongly that their daily lives had been disrupted, felt more financial strain, and worried more about their youth well-being experienced more roadblocks to getting services for the youth. Male caregivers also reported fewer difficulties related to service access. Importantly, the older the youth was when they had been diagnosed with autism, the more service barriers their caregivers reported. We did not see any differences in the level of barriers experienced by youth who lived in urban versus suburban settings, or between white and non-white families. However, when youth lived with their caregivers (rather than, for example, in a group home), fewer quality-related barriers to services were reported. Finally, greater access (but not quality) barriers were linked to youth having more unmet service needs. These findings can help to reduce the barriers to service experienced by autistic adolescents and young adults and their families.

Child Behavior Problems and Parenting Stress in Underserved Families of Children with ASD: Investigation of Family Resources and Parenting Self-efficacy

Behavior problems in children with autism spectrum disorder (ASD) may exacerbate parenting stress. Parenting self-efficacy and family resources may influence this association. We examined cross-sectional statistical mediation effects of parenting self-efficacy on the relationship between child behavior problems and parenting stress and hypothesized that family-level resources moderated this indirect effect. Participants included 132 underserved (Medicaid-eligible) children with ASD (ages 3-13) with racial/ethnic diversity; many (63%) had intellectual disability. Greater externalizing problems were linked with lower parenting self-efficacy, which in turn was associated with increased parenting stress. A larger mediation effect was observed for families with fewer resources. A plausible alternative model (parenting stress mediating parenting self-efficacy) exhibited poorer fit. Implications for family supports and benefits of longitudinal follow-up are discussed.

Autism Prevalence and the Intersectionality of Assigned Sex at Birth, Race, and Ethnicity on Age of Diagnosis

PURPOSE

An official autism diagnosis is required to access timely intervention and is associated with better long-term wellbeing and mental health. Certain demographic characteristics, such as being female or a racially or ethnically minoritized youth, have been associated with significant diagnostic lag. However, it remains unclear how assigned sex, race, and ethnicity interact with each other in predicting the prevalence and age of autism diagnosis.

METHODS

To examine the interactions between assigned sex, race, and ethnicity, we used data from the National Survey of Children's Health (NSCH; 2016 > 2021).

RESULTS

One in 38 children had an autism diagnosis and 3.8 males were diagnosed per 1 female. Hierarchical linear regressions yielded diagnostic delays in some females, particularly those who were non-Hispanic white, Black, and Asian. Ethnic and racial minority children had significantly earlier diagnoses than white and non-Hispanic children when not accounting for sex.

CONCLUSION

This study demonstrates slight increases in reported autism prevalence, a diagnostic lag in some autistic females that was strongly associated with ethnicity, and earlier diagnoses in racial and ethnic minority youth, a finding that may be explained by factors associated with phenotypic differences. This study has important implications for the diagnosis of minority autistic youth, particularly females and females who are non-Hispanic, who may experience a greater propensity for diagnostic delays.

Exploring correlates among Latino/a parents of young children with intellectual and developmental disabilities

Parents of children with intellectual and developmental disabilities (IDD), including autism, experience stress in part due to child and parent characteristics. Although there is significant research about the correlates of parent stress, less is known about stress among Latino/a parents of children with IDD. The purpose of this study was to explore the correlates of empowerment, type of disability, stress, and special education knowledge among 61 Latino/a parents of children with IDD. Findings revealed a positive, significant correlation between empowerment and special education knowledge. Parents of children with autism reported significantly greater special education knowledge and stress. Implications for the future research including the need for longitudinal research are discussed.

Geographic Variation in Preventable Hospitalizations among US Children with Autism

There is a limited amount of research on geographic differences in preventable hospitalizations for ambulatory care sensitive conditions (ACSCs) among children with autism. The purpose of this study was to examine US regional differences in potentially preventable hospital admissions for pediatric inpatients diagnosed with autism. Hospital discharge data for six pediatric preventable conditions were obtained from the 2016-2019 National Inpatient Sample (NIS) under the US Agency for Healthcare Research and Quality. Geographic differences in preventable hospitalizations for children with autism were examined by US census regions and divisions. Multiple logistic regression analyses were conducted to examine child and clinical characteristics associated with ACSCs hospitalization across four US regions; the dependent variable was the likelihood of ACSCs hospitalization. Additionally, this study further explored the variation in preventable hospitalization among racial and ethnic groups for each region or division. Of the 138,305 autistic inpatients aged 2-17 years, about 10% had a primary diagnosis related to ACSCs. The results showed that the highest proportion of preventable hospitalizations for autistic children occurred in the middle Atlantic division of the northeast region. Racial differences were observed across all US regions, particularly in the northeast and south regions. Black children with autism were more likely to be hospitalized for ACSCs compared to White children with autism in three of the four US regions. Our results highlight the significant racial disparities in potentially avoidable hospitalizations among US children with autism. Examining geographic and racial differences in potentially avoidable hospitalizations could inform policy and practice while gaining a better understanding of pediatric patients with autism and where their families access health services. The findings of this study may help policymakers to identify where intervention is needed to tackle health inequities in the accessibility to quality primary care in the US. Further studies with more detailed investigation are recommended to better understand the mechanisms underlying these disparities, and to formulate effective regional policy and clinical practices while considering the unique needs and challenges of underserved children with autism.

Digitally Diagnosing Multiple Developmental Delays using Crowdsourcing fused with Machine Learning: A Research Protocol

Background

Roughly 17% percent of minors in the United States aged 3 through 17 years have a diagnosis of one or more developmental or psychiatric conditions, with the true prevalence likely being higher due to underdiagnosis in rural areas and for minority populations. Unfortunately, timely diagnostic services are inaccessible to a large portion of the United States and global population due to cost, distance, and clinician availability. Digital phenotyping tools have the potential to shorten the time-to-diagnosis and to bring diagnostic services to more people by enabling accessible evaluations. While automated machine learning (ML) approaches for detection of pediatric psychiatry conditions have garnered increased research attention in recent years, existing approaches use a limited set of social features for the prediction task and focus on a single binary prediction.

Objective

I propose the development of a gamified web system for data collection followed by a fusion of novel crowdsourcing algorithms with machine learning behavioral feature extraction approaches to simultaneously predict diagnoses of Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in a precise and specific manner.

Methods

The proposed pipeline will consist of: (1) a gamified web applications to curate videos of social interactions adaptively based on needs of the diagnostic system, (2) behavioral feature extraction techniques consisting of automated ML methods and novel crowdsourcing algorithms, and (3) development of ML models which classify several conditions simultaneously and which adaptively request additional information based on uncertainties about the data.

Conclusions

The prospective for high reward stems from the possibility of creating the first AI-powered tool which can identify complex social behaviors well enough to distinguish conditions with nuanced differentiators such as ASD and ADHD.

Developmental disabilities in Africa: A scientometric review

BACKGROUND

Developmental disabilities are disproportionately more investigated in higher-income countries. However, global prevalence of developmental disabilities indicate that a large proportion of individuals with disabilities reside in low- and middle-income nations.

AIMS

The present work therefore aims to conduct a scientometric review to survey available literature on developmental disabilities in low- and middle-income countries belonging to the continent of Africa.

METHODS AND PROCEDURES

A literature search was conducted on Scopus, where a total of 1720 relevant publications (and an accompanying 66 thousand references) were found, representing research conducted between 1950 to 2022. Then, document co-citation analysis was performed to chart significant co-citation relationships between relevant articles and their cited references.

OUTCOMES AND RESULTS

The generated network based on document co-citation analysis revealed a total of 14 distinct thematic research clusters and 12 significant documents that have been frequently cited in the literature on developmental disabilities in Africa.

CONCLUSIONS AND IMPLICATIONS

The scientometric review revealed a trend of broadening research towards systems of care, away from a medical model of disease. It is projected that future research will continue to capitalise on inter-disciplinary strengths to arrive at a more nuanced understanding of developmental disability from all levels - individuals, families, to communities.

Newborn Auditory Brainstem Responses in Children with Developmental Disabilities

We integrated data from a newborn hearing screening database and a preschool disability database to examine the relationship between newborn click evoked auditory brainstem responses (ABRs) and developmental disabilities. This sample included children with developmental delay (n = 2992), speech impairment (SI, n = 905), language impairment (n = 566), autism spectrum disorder (ASD, n = 370), and comparison children (n = 128,181). We compared the phase of the ABR waveform, a measure of sound processing latency, across groups. Children with SI and children with ASD had greater newborn ABR phase values than both the comparison group and the developmental delay group. Newborns later diagnosed with SI or ASD have slower neurological responses to auditory stimuli, suggesting sensory differences at birth.

Latina Mothers of Young Children With Special Needs: Personal Narratives Capturing the Impact of the COVID-19 Pandemic

The Latino community has been disproportionately impacted by the COVID-19 pandemic, resulting in unique challenges. This paper explores the lived experiences of five Spanish-speaking Latina mothers of young children receiving early childhood special education (ECSE) services during the pandemic. Through in-depth qualitative interviews, this paper focuses on the following research questions: (1) What barriers have Spanish-speaking Latino families encountered in ECSE service delivery during this pandemic? (2) How have families overcome those barriers? Latina mothers describe how despite encountering numerous barriers to ECSE service delivery during the pandemic, they also experienced key areas of support and strength. We discuss how ECSE professionals can leverage these sources of support and strength in a culturally responsive manner to better support the Latino community through the pandemic. By presenting interviews with Latina mothers, this paper offers a unique interpretation of their experience, which is often left out of educational research.

Disparities in Family-Centered Care Among US Children and Youth with Special Healthcare Needs

Cross-sectional analyses of 4 nationally representative samples indicate disparities in family-centered care occur among US children and youth with special healthcare needs by race and ethnicity, family income and composition, insurance coverage, and healthcare setting. Measured confounds including children's health and impairment severity do not explain the disparities.

Racial and Ethnic Disparities in Geographic Access to Autism Resources Across the US

Importance

While research has identified racial and ethnic disparities in access to autism services, the size, extent, and specific locations of these access gaps have not yet been characterized on a national scale. Mapping comprehensive national listings of autism health care services together with the prevalence of autistic children of various races and ethnicities and evaluating geographic regions defined by localized commuting patterns may help to identify areas within the US where families who belong to minoritized racial and ethnic groups have disproportionally lower access to services.

Objective

To evaluate differences in access to autism health care services among autistic children of various races and ethnicities within precisely defined geographic regions encompassing all serviceable areas within the US.

Design, Setting, and Participants

This population-based cross-sectional study was conducted from October 5, 2021, to June 3, 2022, and involved 530 965 autistic children in kindergarten through grade 12. Core-based statistical areas (CBSAs; defined as areas containing a city and its surrounding commuter region), the Civil Rights Data Collection (CRDC) data set, and 51 071 autism resources (collected from October 1, 2015, to December 18, 2022) geographically distributed into 912 CBSAs were combined and analyzed to understand variation in access to autism health care services among autistic children of different races and ethnicities. Six racial and ethnic categories (American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or other Pacific Islander, and White) assigned by the US Department of Education were included in the analysis.

Main Outcomes and Measures

A regularized least-squares regression analysis was used to measure differences in nationwide resource allocation between racial and ethnic groups. The number of autism resources allocated per autistic child was estimated based on the child's racial and ethnic group. To evaluate how the CBSA population size may have altered the results, the least-squares regression analysis was run on CBSAs divided into metropolitan (>50 000 inhabitants) and micropolitan (10 000-50 000 inhabitants) groups. A Mann-Whitney U test was used to compare the model estimated ratio of autism resources to autistic children among specific racial and ethnic groups comprising the proportions of autistic children in each CBSA.

Results

Among 530 965 autistic children aged 5 to 18 years, 83.9% were male and 16.1% were female; 0.7% of children were American Indian or Alaska Native, 5.9% were Asian, 14.3% were Black or African American, 22.9% were Hispanic or Latino, 0.2% were Native Hawaiian or other Pacific Islander, 51.7% were White, and 4.2% were of 2 or more races and/or ethnicities. At a national scale, American Indian or Alaska Native autistic children (β = 0; 95% CI, 0-0; P = .01) and Hispanic autistic children (β = 0.02; 95% CI, 0-0.06; P = .02) had significant disparities in access to autism resources in comparison with White autistic children. When evaluating the proportion of autistic children in each racial and ethnic group, areas in which Black autistic children (>50% of the population: β = 0.05; <50% of the population: β = 0.07; P = .002) or Hispanic autistic children (>50% of the population: β = 0.04; <50% of the population: β = 0.07; P < .001) comprised greater than 50% of the total population of autistic children had significantly fewer resources than areas in which Black or Hispanic autistic children comprised less than 50% of the total population. Comparing metropolitan vs micropolitan CBSAs revealed that in micropolitan CBSAs, Black autistic children (β = 0; 95% CI, 0-0; P < .001) and Hispanic autistic children (β = 0; 95% CI, 0-0.02; P < .001) had the greatest disparities in access to autism resources compared with White autistic children. In metropolitan CBSAs, American Indian or Alaska Native autistic children (β = 0; 95% CI, 0-0; P = .005) and Hispanic autistic children (β = 0.01; 95% CI, 0-0.06; P = .02) had the greatest disparities compared with White autistic children.

Conclusions and Relevance

In this study, autistic children from several minoritized racial and ethnic groups, including Black and Hispanic autistic children, had access to significantly fewer autism resources than White autistic children in the US. This study pinpointed the specific geographic regions with the greatest disparities, where increases in the number and types of treatment options are warranted. These findings suggest that a prioritized response strategy to address these racial and ethnic disparities is needed.

Perceptions of the Professionals and Parents of Children with Autism Spectrum Disorders About Autism Services; A Qualitative Study

In this qualitative study, we aimed to explore the challenges of providing services and supports for children with autism spectrum disorders (ASD) and their families from the perceptions of professionals and parents of children with ASD. We classified the results of the study into three key categories including shortcomings in the management of children with ASD; shortcomings of supportive programs and facilities for children with ASD and their families; and organizational challenges in providing services for these children. We analyzed data using the content analysis method. The results showed that there is a wide range of challenges in providing sufficient and high-quality services for children with ASD and empowerment programs for their parents.

Using Telehealth to Provide Interventions for Children with ASD: a Systematic Review

As the need for accessible interventions for autism spectrum disorder (ASD) grows, empirically supported telehealth interventions become increasingly necessary. With the current COVID-19 public health crisis, in-person interventions have become largely infeasible; therefore, it is crucial that providers have information regarding the effectiveness of telehealth interventions. This systematic review evaluates and synthesizes existing group design research on telehealth ASD interventions. Sixteen articles were evaluated on implementer and child-level intervention outcomes as well as factors that promote equitable access to intervention. Findings suggest that telehealth programs are highly acceptable, comparable to face-to-face interventions, and can be an effective method of training implementers in interventions. Recommendations for future research and for maximizing equitable access to telehealth interventions are presented.

Short report: Experiences of Caregivers Participating in a Telehealth Evaluation of Development for Infants (TEDI)

A growing literature supports the feasibility and validity of telehealth-based assessments for autism spectrum disorder (ASD). Better understanding families' experiences is crucial for sustained use beyond the COVID-19 pandemic. This study qualitatively examines caregiver experiences with the Telehealth Evaluation of Development for Infants (TEDI) protocol to better understand benefits and challenges of telehealth-based evaluations. Caregivers (N = 32) completed an online survey following a telehealth-based evaluation with their 6-12 month-old infants. Open-ended text responses to queries about perceived benefits, challenges, and suggestions for future adaptations were coded. Most caregivers reported positive experiences with minor feedback relating to tailoring of individual needs. Responses suggest the TEDI is a feasible approach and provide guidance for components of successful telehealth evaluations more broadly.

The Scholarly Neglect of Black Autistic Adults in Autism Research

Black autistic individuals, regardless of age, have not been centered in autism research. Instead, they often exist on the margins-on the periphery of autism research. In fact, Black autistic adults are largely absent from the literature. Most participants in autism research are majority-white autistic individuals and families. In this conceptual article, we use intersectionality and Dis/ability Studies and Critical Race Theory theories to contextualize Black autistic adults' experiences. Second, we argue that systemic disparities and methodological concerns are two contributors to the scholarly neglect of Black autistic adults in autism research. Third, we provide guidelines to support researchers in moving from neglect to inclusive research with Black autistic adults.

Socio-demographic disparities in receipt of clinical health care services during the COVID-19 pandemic for Canadian children with disability

BACKGROUND

Little is known about the experience of receiving in-person and virtual clinical health care services during the COVID-19 pandemic for Canadian children with developmental disabilities and delays facing multiple layers of vulnerability (e.g., low income, low educational attainment families). We examined the relationship between socio-demographic factors and the receipt of these services (physical and mental health services) during COVID-19 for Canadian children with these conditions.

METHODS

Data collected in Canada for the Global Report on Developmental Delays, Disorders and Disabilities were used. The survey: (1) was developed and disseminated in collaboration with caregivers of children with disabilities, (2) included topics such as response to the pandemic and receipt of services and supports, and (3) documented the experiences of a non-random convenience sample of caregivers of children (any age) with these conditions during and prior to the pandemic. We used four logistic regression models to assess the association between socio-demographic factors and receipt of services.

RESULTS

Being a single parent, having low educational attainment (high school or less), having low income (making less than $40,000 per year), working less than full time (working part-time, working reduced hours due to COVID, retired, stay home parent or student), as well as male gender and older age of the child with disability were factors associated with decreased likelihood of receiving services.

CONCLUSION

Our findings point to the need for tailoring services for families of children with disabilities, particularly low socioeconomic status families, to ensure continuity of care during public health emergencies.

Barriers to Service Access for Immigrant Families of Children With Developmental Disabilities: A Scoping Review

This scoping review explores (a) barriers faced by immigrant families of children with intellectual and developmental disabilities (IDD) when accessing healthcare-related services in the United States, (b) where research stands based on the health disparity research framework, and (c) implications for future health disparities research with this population. Our scoping review found 26 empirical studies published between 2000 and 2020 that met our inclusion criteria. Data were extracted and synthesized based on the stages of research outlined in the health disparity research framework. Overall, immigrant families experienced barriers on multiple levels including patient, provider, and healthcare system levels. Studies focusing on detecting and reducing disparities are emerging. We conclude with recommendations for future research and practice with immigrant families of children with IDD.

Black Children With Developmental Disabilities Receive Less Augmentative and Alternative Communication Intervention Than Their White Peers: Preliminary Evidence of Racial Disparities From a Secondary Data Analysis

PURPOSE

Ensuring equitable access to augmentative and alternative communication (AAC) intervention services for children with complex communication needs (CCN) is crucial. Evidence suggests that racial disparities exist in access to communication interventions, disadvantaging Black children. However, no research has investigated specifically the evidence for racial disparities in AAC services for children with developmental disabilities and CCN.

METHOD

The current study applied post hoc data analysis methods within a preexisting, open-access data set to explore preliminary evidence of racial disparities in AAC intervention. Amount of AAC intervention was compared for Black versus white ¹ preschool students at study initiation (M _age = 3;8 [years;months]) and 2 years later at study completion (M _age = 5;10).

RESULTS

Black preschool students were reported to receive significantly less AAC intervention per week as compared to their white peers, both at study initiation and 2 years later. By study end, 75% of the Black children were receiving less than 60 min of AAC intervention per week, an inadequate amount to achieve meaningful gains given their significant disabilities.

CONCLUSIONS

It is unclear what mechanisms may contribute to the observed disparities; however, it is critical that concrete steps are taken by individual speech-language pathologists, school districts, preservice preparation programs, and researchers to identify inequities in AAC services and take actions to rectify them. Future research is essential to investigate the potential factors contributing to inequalities and determine effective interventions to address them.

Gendered racial disparities in health of parents with children with developmental disabilities

Background

There is little information on (1) how adverse experiences in early life are associated with the risk of having a child with health problems and (2) whether the health of racial and gender minority groups would be particularly compromised if they have developmentally disabled (DD) children.

Objective

By integrating life-course perspectives and the intersectionality framework, we examine (1) the extent to which parents’ early-life adversities (ELAs) are associated with having children with DD or other health issues and (2) whether the association between having DD children and parental (physical and mental) health varies across race–gender groups after accounting for ELAs.

Methods

Using data from Black and White parents from the Midlife in the US Study (n = 7,425; 18% Black), we employed (1) multinomial logistic regression models to investigate the degree to which ELAs are associated with parenting types (having a child with DD, a child with recent illness, or a child without these health issues) and (2) multiple regression models with a three-way interaction term to investigate whether the gender–parenting type association differs by race.

Results

With more adversities, the probability of having children with health issues increases for all race–gender groups, but most dramatically for Black women. Having DD children is associated with more chronic illnesses and functional limitations for women than men, with the largest burden for Black women, yet neither gender nor racial differences in depressive symptoms. Our results highlight that while raising children with DD takes a toll on the health of all parents, the strain might be larger for Black mothers.

Conclusion

The adverse effects of parenting a child with DD is more pronounced for Black women than for other race–gender groups indicating opportunities to promote community-based programs for these parents.

Developing undergraduate autism education for medical students: a qualitative study

BACKGROUND

Autistic adults and children experience considerable health inequalities and have high rates of premature mortality, hospital admissions and emergency department visits. This is in part due to a lack of autism awareness in the healthcare and social care workforce. A new educational programme, Time for Autism (TfA), for medical students is being developed to address this challenge. This qualitative study was undertaken to support the development of the new programme in order to (1) understand the medical care experiences of parents of autistic children and (2) assess their views on the acceptability of the new TfA programme and willingness to be involved.

METHODS

A convenience sample of 11 parents of autistic children were recruited across the South of England. The ages of the autistic children ranged from 3 to 17 years. Semistructured interviews were completed between October and December 2019. Interview transcripts were analysed using thematic analysis.

RESULTS

Three key themes were identified: diagnosis, experiences of doctors and TfA considerations. There was support for and willingness to take part in a dedicated autism education programme for medical students, and constructive feedback to inform and improve its delivery.

CONCLUSION

The findings from this study provide insights into the medical care experiences of parents/carers of autistic children. Understanding how parents/carers of autistic children would like medical care to be improved can be used to develop TfA and other autism programmes. Parental/carer support for the development of and involvement in an autism medical education programme enhances the feasibility of the new programme.

A systematic review of the use of telehealth to facilitate a diagnosis for children with developmental concerns

BACKGROUND

Telehealth can reduce the gap between developmental concern and diagnosis. Evaluation of telehealth methods is needed for providers to make decisions about using telediagnostic assessments.

AIM

This systematic review examined telehealth in facilitating a diagnosis for children with developmental concerns and assessed 1) study characteristics and type of diagnostic evaluation; 2) comparison of telehealth technologies to in-person diagnostic methods; 3) feasibility and acceptability of telehealth technologies; and 4) methodological quality.

METHOD AND PROCEDURES

Peer-reviewed studies from PsycINFO, CINAHL, Web of Science, PubMed, Embase, and Cochrane published January 2000-July 2021 were searched using "telehealth" AND "developmental concern" AND "diagnosis". Data extraction included study characteristics, diagnostic evaluation, technology, diagnostic accuracy, feasibility, and acceptability. Methodological quality was assessed using NHLBI tools.

OUTCOMES AND RESULTS

Nine studies met inclusion. Children with suspected FAS, social-emotional concerns, suspected genetic conditions, and failed hearing screenings received a telediagnosis. Evaluations included dysmorphology, feeding, neurological, developmental, audiological, and psychiatric. Seven studies used videoconferencing in real-time and two used Store-and-Forward methods. High diagnostic agreement occurred between face-to-face and remote methods. Stakeholders reported high satisfaction and feasibility. Many of the studies were rated as fair quality.

CONCLUSIONS AND IMPLICATIONS

Findings underscore partnership models between local providers and remote specialists. Rigorous study designs with larger samples covering a wider range of developmental domains are needed to provide a stronger empirical base for providers.

Assessing the Burden on Caregivers of MECP2 Duplication Syndrome

BACKGROUND

MECP2 duplication syndrome (MDS) is a rare neurogenetic disorder characterized by severe neurodevelopmental disorder, refractory epilepsy, recurrent infections, and functional gastrointestinal problems. Because of the significant clinical problems and lifelong disability of children with this disorder we hypothesized that the burden on parents/caregivers of these children is significant. However, there are no reports of the impact on caregivers of individuals with MDS.

METHODS

We developed and validated a burden scale to investigate the challenges of caregivers of children and adults with MDS and identified factors contributing to the burden on caregivers. We developed a Health Insurance Portability and Accountability Act-compliant patient registry for families with MDS and delivered caregiver burden survey through the registry.

RESULTS

Of 237 completed surveys, 101 were eligible for the study. We identified increased levels of self-perceived anxiety, depression, and emotional exhaustion in caregivers that correlated with higher burden scores. Epilepsy was the only clinical feature that caused a higher burden in caregivers of individuals with MDS. In addition, a higher burden was found in Hispanic caregivers. The duration of care negatively correlated with burden score.

CONCLUSIONS

This is the first study to investigate the burden on caregivers of individuals with MDS and identify several factors contributing to increased burden. Addressing these concerns has the potential to improve the health of individuals with MDS and contribute to the well-being of their caretakers.

Autism presentation in female and Black populations: Examining the roles of identity, theory, and systemic inequalities

LAY ABSTRACT

Although the prevalence of autism has been rising in recent years, disparities in diagnosis still remain. Female and Black populations in the United States are diagnosed later, are more likely to have an intellectual disability, and are excluded from research as well as services designed for autistic individuals. Autistic Black girls are effectively invisible in the current scientific literature. Intersectional theory, which looks at a person as a whole, examines models that are inclusive toward diverse gender, ability, and racial/ethnic backgrounds. This theory may be a useful approach to clinical and research work with autism so that practitioners may be most effective for the whole population of autistic people. The authors recommend research focusing on inclusion of autistic populations with intellectual disability and research studies that include evaluations as part of the procedure. Clinically, the authors recommend a focus on screening all young children for autism and improving provider knowledge in working with diverse autistic populations.

The creator did not give me more than I can handle: Exploring coping in parents of Black autistic children

LAY ABSTRACT

Parents of Black autistic children use several strategies to cope with daily stressors. These strategies include seeking social support, self-care, and optimism. We asked parents about their experiences receiving treatment services for their autistic child and how they reduce parenting stress. Twenty-two parents completed a coping survey and participated in individual interviews. Few studies have explored the experiences of Black families raising autistic children, and it's important for healthcare and other systems of care to understand the role culture, race, and ethnicity play in the use of coping strategies. In our study, the majority of parents relied on social support to relieve stress and identified partners, family, and community members, as their most useful sources of support. Connecting with other parents of autistic children, through support groups and social media, also helped parents relieve stress. Parents discussed using self-care activities (e.g. church, exercising, listening to music) to cope with stressors. Several parents described how prayer and meditation helped them reframe stressful situations and gain more patience and appreciation for "what's important." The findings of this work demonstrate the need for professionals to have ongoing and deeper conversations about the ways in which parents deal with stressors. In particular, clinicians should leverage the strengths of Black families and promote strategies that are culturally informed and engaged.

Analysis of Race and Sex Bias in the Autism Diagnostic Observation Schedule (ADOS-2)

IMPORTANCE

There are long-standing disparities in the prevalence of autism spectrum disorder (ASD) across race and sex. Surprisingly, few studies have examined whether these disparities arise partially out of systematic biases in the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), the reference standard measure of ASD.

OBJECTIVE

To examine differential item functioning (DIF) of ADOS-2 items across sex and race.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional study of children who were evaluated for ASD between 2014 and 2020 at a specialty outpatient clinic located in the Mid-Atlantic region of the US. Data were analyzed from July 2021 to February 2022.

EXPOSURES

Child race (Black/African American vs White) and sex (female vs male).

MAIN OUTCOMES AND MEASURES

Item-level biases across ADOS-2 harmonized algorithm items, including social affect (SA; 10 items) and repetitive/restricted behaviors (RRBs; 4 items), were evaluated across 3 modules. Measurement bias was identified by examining DIF and differential test functioning (DTF), within a graded response, item response theory framework. Statistical significance was determined by a likelihood ratio χ2 test, and a series of metrics was used to examine the magnitude of DIF and DTF.

RESULTS

A total of 6269 children (mean [SD] age, 6.77 [3.27] years; 1619 Black/African American [25.9%], 3151 White [50.3%], and 4970 male [79.4%]), were included in this study. Overall, 16 of 140 ADOS-2 diagnostic items (11%) had a significant DIF. For race, 8 items had a significant DIF, 6 of which involved SA. No single item showed DIF consistently across all modules. Most items with DIF had greater difficulty and poorer discrimination in Black/African American children compared with White children. For sex, 5 items showed significant DIF. DIF was split across SA and RRB. However, hand mannerisms evidenced DIF across all 5 algorithms, with generally greater difficulty. The magnitude of DIF was only moderate to large for 2 items: hand mannerisms (among female children) and repetitive interests (among Black/African American children). The overall estimated effect of DIF on total DTF was not large.

CONCLUSIONS AND RELEVANCE

These findings suggest that the ADOS-2 does not have widespread systematic measurement bias across race or sex. However, the findings raise some concerns around underdetection that warrant further research.