Race Influences Parent Report of Concerns about Symptoms of Autism Spectrum Disorder

Background: Despite progress in the early identification of autism spectrum disorder (ASD), Black children are diagnosed later than their White peers (Mandell et al., 2007, 2009). Mandell and colleagues (2007) found that Black children were often misdiagnosed with conduct and oppositional defiant disorders prior to an ASD diagnosis. The researchers posited that Black parents may relate concerns about their children’s development to healthcare providers in ways that de-emphasize ASD-specific symptoms and emphasize disruptive behaviors, which may impact clinicians’ consideration of ASD.

Objectives: We tested the hypothesis that compared to White parents, Black parents of children with ASD would report fewer concerns about their children’s behaviors specific to ASD, and would be more likely to report concerns about children’s disruptive behaviors.

Methods: A sample of parents (N=207; 135 White, 72 Black parents) and their 18-40 month old toddlers (mean age=25.84 m, SD=4.74) with ASD participated. After screening positive for ASD risk, but prior to the diagnostic evaluation, parents completed free-response questions soliciting concerns about their children’s development. Parent responses were coded for the presence or absence of 10 domains of concerns, which were grouped into ASD-specific concerns (i.e., speech/communication, restricted and repetitive behaviors (RRB), social deficits, and directly naming autism/ASD as a concern) or non ASD-specific concerns (e.g., general developmental concerns, disruptive behavior concerns), adapted from Ozonoff and colleagues (2009) by Richards and colleagues (2016). ASD symptom severity, measured by the domain and total severity scores from the Autism Diagnostic Observation Schedule (ADOS-2; Gotham et al., 2009; Hus et al., 2014), were used as covariates to control for the possibility that racial differences in ASD-specific concerns are due to group differences in symptom severity in our sample.

Results: White parents (M=2.47, SD=1.31) endorsed a greater number of categories of concerns (i.e., the sum of all 10 concern categories) than Black parents (M=1.85, SD=.94), t(187.01)=3.91, p<.001, partial η²=.08. There was a significant effect of race on ASD-specific concerns F(1,167)=10.04, p<.001, partial η²=.06. Black parents reported significantly fewer ASD-specific concerns than White parents (M_diff=.42, SE=.13, p<.001). In particular, Black parents were less likely than White parents to report concerns about social deficits, χ²(3)=8.217, p=.04 and RRB, χ²(4)=18.97, p<.001, even after controlling for ASD symptom severity. There was not a significant effect of race on non ASD-specific concerns (p=.28) or disruptive behavior concerns specifically (p=.17).

Conclusions: Reporting fewer ASD-specific concerns by Black parents may impact providers’ abilities to identify children in need of evaluations. There was not a racial difference in parent report of concerns about children’s disruptive behaviors, suggesting that underreporting of ASD-specific concerns is not likely explained by parent interpretation of ASD symptoms as disruptive behaviors. Future studies should examine factors that may explain report of fewer ASD-specific concerns by Black parents of children with ASD, such as less knowledge about ASD and cultural differences in expectations or interpretations of children’s behaviors or willingness to report concerns specific to ASD. Future research should also examine other factors, such as clinician biases, that may contribute to delayed diagnosis for Black children with ASD.