Disparity in Report of Autism-Related Behaviors by Child Sex and SES: Findings From a Population-Based Study in Taiwan

Background: Evidence indicates that many people live with ASD without being diagnosed.  Such under-diagnosis underscores the urgent need for population-based studies that provide full coverage of case identification in the target population.  Though providing clinical assessments to each individual in a population is not practical, multi-stage case identification that involves screening followed by clinical evaluation is a feasible way to identify ASD, especially for populations without complete autism or autism-related services registries.  Screeners that aim to identify individuals at high risk for ASD are vital for multi-stage case identification.  While the majority of ASD screeners for children are caregiver-reported, a biased report would make the screening result invalid.  In addition to psychometrics of screening tools, investigating how SES factors affect reporting deserves attention.  Understanding potential biases due to SES will improve the identification of autism-related behaviors and reduce false positives and negatives.

Objectives:  To examine disparities in caregiver-reported SCQ scores by child sex and SES factors.

Methods:  A population-based epidemiologic study of autism in children aged 6-8 involving a multi-stage case identification design was conducted in PingTung, Taiwan from 2008-2010.  The SCQ rates autism-related behaviors and was used as a screener to identify children at high risk for ASD.  The SCQ was translated and back-translated into traditional Chinese Mandarin and pilot tested before its use in this population.  Studies from Western countries recommend a cut-point of 15 on the SCQ for differentiating between likely ASD and non-ASD diagnoses.  This analysis includes a total of 2279 primary caregivers (60.0% mothers, 17.5% fathers, 22.5% grandparents and others) who completed the screener on their child (1083 boys and 1156 girls). 

Results:  Fathers reported significantly higher SCQ scores (more behavioral concerns) than did mothers and other caregivers (p-values all <.0001).  As education levels of mother’s and fathers’ increased, the reported SCQ scores decreased with p-values <.001 for fathers and <.0001 for mothers.  As expected, SCQ scores of children born preterm (7.66 ± 5.71) were significantly higher than those born full term (6.25 ± 4.63), with p<.0001. Using 15 as a cut-off, compared to fathers with an Associate/college degree, fathers with an education level <=middle school were 4 times (OR= 4.36, 95%CI: 2.76-6.90) more likely to report SCQ>=15, while those with a high school degree were almost twice (OR=1.82, 95%CI: 1.17-2.82) as likely to do so.  A similar pattern was observed with mother’s education level where <=middle school was 5.79 times (95%CI: 3.58-9.36) and high school was 1.83 times (95%CI: 1.15-2.92) more likely to report SCQ>=15 compared to Associate/college.  Moreover, children born preterm were more than twice (OR=2.72, 95%CI: 1.77-4.19) as likely as full term children to have a reported SCQ score>=15.

Conclusions: Caregiver reported autism-related behaviors are associated with respondents’ characteristics in this large scale population-based study in Taiwan.  Fathers reported more behavioral issues in their child than did mothers and other caregivers; and lower education levels were associated with reports of clinically concerning autism-related behaviors.  Psychometrics of the SCQ and validation of data using multiple respondents on the same child will be discussed.