Impact of Race/Ethnicity on Diagnostic Outcomes for Children Evaluated at an Autism Center

Background: Autism Spectrum Disorder (ASD) is a phenomenon that occurs across race and ethnicity with consistent biological symptoms (Bernier, 2010). Practitioners must be prepared to work with racially and linguistically diverse populations as developmental perspectives are not applied equally across cultures (Bronheim, 2015). Historically, there have been disparities in rates and age of ASD diagnosis based upon race. Mandell (2002) found that on average, black children were diagnosed 1.4 years later than their white counterparts. Furthermore, Mandell (2007) found that after entry into specialty care, black children who would ultimately receive a diagnosis of ASD were three times as likely as white children to receive another diagnosis first. High patient volume centers focusing on ASD care regardless of patients’ ability to pay offer unique opportunities to study demographic implications on diagnosis and treatment.

Objectives: To investigate differences in diagnostic outcomes based on race and ethnicity at a high-volume autism center in the Western United States.

Methods: Participants were drawn from a de-identified clinical records dataset of children (n=4986) who visited an autism center for diagnostic evaluation over an 8-year period from 2010 to 2018. Diagnoses (n=184) were collapsed into categories and coded as to whether such diagnoses were made. Categories included ASD (including Autistic Disorder, Asperger’s Disorder, and PDD-NOS from the DSM-IV-TR and Autism Spectrum Disorder from the DSM-5), ADHD, Behavior/Conduct, Anxiety, and Mood Disorders.

Results: Participants ranged in age from 1- to 27-years-old (M=7.70, SD=4.21) and the mean age at first visit was different across racial/ethnic categories (F(5, 4980)=16.399, p<0.001). The clinic population had higher rates of racial/ethnic minorities than would be expected compared to census rates for the region. A chi-square test was performed to examine the relationship between race/ethnicity and various diagnostic outcomes. The relationship between race/ethnicity and ASD was significant, χ²=(5, N=4,986)=19.01 p<0.001. See Table 1 for proportions of those receiving a diagnosis. The relationship between race/ethnicity and ADHD, Behavior/Conduct, Anxiety, and mood disorders were also all significant and ranged from p<0.05 to p<0.001.

Conclusions: The present study found differences in diagnostic outcomes based upon race/ethnicity. However, the findings were inconsistent with previous reports (Mandell, 2009) and may be explained by a range of factors. The first may be that practitioners at the center practice with high levels of multicultural competence. A second explanatory factor could be specific to the clinic population. The mean sample diagnostic evaluation age of 7.7 years is older than mean age of diagnosis in the community, suggesting that many children are detected and diagnosed earlier in other programs such as birth to three centers. The higher racial/ethnic minority rate and higher rate of ASD diagnosis of underserved communities observed in this clinic sample may suggest that the center, and similar centers nationally and internationally, may play a role in providing services to children with ASD that are missed in the community.