Characteristics of Children Receiving an Initial Diagnosis of ASD in Jerusalem

Background: Early access to services and better prognosis depend on the early diagnosis of ASD (Zwaigenbaum et al, 2015). Studies have consistently shown discrepancies in age of diagnosis between children from varying SES, cultural and ethnic backgrounds (Daniels & Mandell, 2013; Durkin et al., 2017). Recent studies have examined some of these issues in Israel, finding significant divergences between age of diagnosis across religious and ethnic groups (Raz et al, 2015; Davidovitch et al., 2013). The data in these studies have come from large national databases and provide important perspective on national trends. This broad vantage point necessarily sacrifices a nuanced understanding of local trends.

Jerusalem is comprised of three primary groups of residents: secular and modern religious Jews (SMRJ), ultra-Orthodox Jews, and Arabs. The mixed nature of the city provides a unique opportunity to examine the interaction between demographics and clinical characteristics of children receiving a diagnosis of ASD.

Objectives: To examine the interaction between the sociodemographic and clinical characteristics of children receiving an initial diagnosis of ASD in a public child development center in West Jerusalem. Specifically, to understand factors associated with greater severity of autism symptoms as measured by the ADOS total score.

Methods: Chart review of every child diagnosed with ASD at Leumit Healthcare Child Development Clinic in West Jerusalem from 2011-2016. Information extracted included: age of referral, age of diagnosis, symptom severity, ethnicity, age and educational levels of parents, and presence of siblings with an ASD diagnosis.

Results: Of the 126 children diagnosed with ASD between 2011-2016, 37 were SMRJ, 69 ultra-Orthodox and 20 Arabs. Most were males (79%) with a mean age of diagnosis of 56.6 months (SD:31.9, range:13-172). While the general trend included fewer children being referred for evaluations as their age increased, it is noteworthy that after the age of 6 no Arab children were seen for an evaluation. Even more noteworthy is that all Arab children diagnosed with ASD were non-verbal.

A linear regression to predict autism severity (as measured by ADOS total score) shows that the linear combination of gender, ethnicity, current age, and relatives with ASD successfully predicted ASD severity (adjusted R² = 19.7, F (5, 98) = 6.04, p < .001), with lower age at time of referral (β = -0.38, p < .001) and Arab ethnicity (β = 0.20, p < .05) predicting the dependent variable. In contrast with previous findings, no differences were found between SMRJ and ultra-Orthodox Jews.

Conclusions: This examination of a public child development center in Jerusalem indicates that Arab children are likely to be referred for an evaluation only if they were under the age of six and non-verbal. Arab ethnicity, independent of child’s age, is associated with more severe ASD symptomatology. Additionally, all children diagnosed at earlier ages are likely to be more severely affected by ASD. These findings bear significance regarding public health policy relating to awareness, screening and referral for ASD evaluations in sectors of Israeli society.