摘要：Objectives. We sought to examine racial and ethnic disparities in the recognition of autism spectrum disorders (ASDs). Methods. Within a multisite network, 2568 children aged 8 years were identified as meeting surveillance criteria for ASD through abstraction of evaluation records from multiple sources. Through logistic regression with random effects for site, we estimated the association between race/ethnicity and documented ASD, adjusting for gender, IQ, birthweight, and maternal education. Results. Fifty-eight percent of children had a documented autism spectrum disorder. In adjusted analyses, children who were Black (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.64, 0.96), Hispanic (OR = 0.76; CI = 0.56, 0.99), or of other race/ethnicity (OR = 0.65; CI = 0.43, 0.97) were less likely than were White children to have a documented ASD. This disparity persisted for Black children, regardless of IQ, and was concentrated for children of other ethnicities when IQ was lower than 70. Conclusions. Significant racial/ethnic dispatrities exist in the recognition of ASD. For some children in some racial/ethnic groups, the presence of intellectual disability may affect professionals' further assessment of developmental delay. Our findings suggest the need for continued professional education related to the heterogeneity of the presentation of ASD. There is increasing evidence that autism spectrum disorders (ASDs) are often diagnosed several years after the onset of symptoms or are misdiagnosed as other disorders 1 – 3 even though an experienced clinician can accurately diagnose ASD in children as young as 2 years. 4 – 7 Delay in ASD diagnosis may be because of inadequate screening practices, 8 – 10 slow response to parental concerns, 11 , 12 or a lack of awareness of symptoms that manifest early in life. 13 , 14 Conversely, misdiagnosis is likely because of the similarity of certain features of ASD with other conditions that manifest in childhood. 15 – 17 For example, symptoms frequently observed in children with ASD, such as hyperactivity and behavioral difficulties, can lead clinicians to diagnose attention deficit/hyperactivity disorder instead of ASD. 18 , 19 The presence of repetitive behaviors may lead to a diagnosis of obsessive–compulsive disorder, and noncompliance related to resistance to change may lead to a diagnosis of oppositional-defiant disorder. 20 , 21 Early diagnosis of ASD also is complicated by intellectual disability, which occurs in 50% to 60% of cases of children with more-severe symptom presentation 22 and can result in a primary diagnosis of developmental delay or intellectual disability. We have used “intellectually disabled” to describe children with IQs lower than 70. This pattern of delayed and missed ASD diagnosis may be exacerbated among medically underserved ethnic and racial minorities. A large body of research documents ethnic and racial disparities in the diagnosis and treatment of many health conditions 23 ; evidence has been inconclusive, however, for disparities in the diagnosis of ASD. Recent epidemiological studies have found conflicting results on ethnic or racial differences in the community prevalence of ASD. 3 , 22 , 24 Studies that have examined racial and ethnic differences in the age and accuracy of identification of ASD have also produced mixed results. For example, Mandell et al. studied Medicaid claims data from 1993 to 1999 and found that Black children were identified as having ASD later 25 and were more likely to be diagnosed with conduct disorder or adjustment disorder 26 than were White children. A survey of a large convenience sample of parents of children with ASD in the same geographic area, however, found no ethnic differences in age of diagnosis. 1 A report from the Centers for Disease Control and Prevention found no difference between the proportions of non-Hispanic White and non-Hispanic Black parents responding positively to the question, “Has a health care professional ever told you that your child has autism?” but this study was underpowered to test differences between the reported prevalence of ASD in White and Black children. Hispanic parents, however, were less likely than were non-Hispanic parents to say that their child had been diagnosed with ASD. 27 The major limitation of these studies of disparities in the identification of ASD is that only children with a documented diagnosis of ASD were included. This strategy excludes children who meet diagnostic criteria but have not been identified by the health care or education systems as having ASD. Therefore, it is not possible to tell whether observed ethnic differences are because of true group differences in prevalence or of disparities in diagnostic practices. Estimates of ethnic and racial disparities in the identification of ASD can inform the development of interventions to ameliorate them. For instance, if professionals consistently miss the diagnosis of ASD in certain groups, programs can be designed to provide better access to screening, referral, and education about developmental milestones. We examined ethnic and racial disparities in the identification of ASD. Data were collected by the Centers for Disease Control and Prevention–sponsored Autism and Developmental Disabilities Monitoring (ADDM) network, which consists of multiple sites throughout the United States that collect population-based data on children who are at risk for ASD. Because case identification relies on record review rather than previous ascertainment by the health care or education systems, this dataset is an ideal way to examine whether the identification of ASD is dependent on ethnicity or race. On the basis of previous studies, we hypothesized that Black and Hispanic children meeting diagnostic criteria for ASD would be less likely than White children to be identified as such in their health and education records.
