The Impact of Urbanicity on Diagnosis and Treatment of ASD

Background:

Children with autism spectrum disorders (ASD) living in rural areas may experience difficulties accessing health and educational services, most notably access to well-established interventions such as applied behavioral analysis (ABA).

Objectives:

To examine diagnostic patterns, educational opportunities, and access to ABA by urban-rural categories for Missouri children with ASD (age<18) enrolled in a national autism registry (Interactive Autism Network). 

Methods:

Using a web-based interface, parents of 351 children (83% male) living in Missouri reported information about their child’s diagnosis, education, and treatments. The number of children with complete data regarding diagnosis and education was 251 and regarding treatments was 313. Of these, 56 non-Asperger’s children were receiving ABA therapies at enrollment (M age = 6.08 years; SD= 2.98). Results were analyzed by urbanicity using the 2006 National Center for Health Statistics Urban-Rural Classification Scheme: 61% of children lived in large metro areas (12% large central metro; 49% large fringe metro), 21% in smaller metro areas (9% medium metro; 12% small metro), and 18% in non-metro areas (8% micropolitan; 10% rural). To determine differences across the urban-rural continuum for access to ABA, the number of young children (3-9 years) participating in ABA intervention at the time of enrollment (n = 38) was compared to those within the same age range who did not report ABA therapy at enrollment (n = 105). 

Results:

Although there was no difference in age of first concern, children living in smaller metro/non-metro areas  were less likely to be diagnosed before age three than children living in the greater metro areas of St. Louis and Kansas City (29% and 53%, respectively; p<.001 ). They had fewer educational options, with 76% attending public school compared to 53% for those in large metro areas (p<.01). Those in large metro areas had access to specialized public and private schools that were not an option for most children living in more rural areas. There was no statistically significant difference between large metro areas and more rural areas in the percentage of children with an aide (47% and 55%, respectively); however, of those children who did have an aide, those living in large metro areas were less likely to have a full-time aide than those living in more rural areas (36% and 64%, respectively; p<.05). Children in large central metro areas were less likely to have classroom opportunities for inclusion with typically developing peers than those in less urban areas (63% and 86%, respectively; p<.01).  Furthermore, young children in smaller metro/non-metro areas were less likely to receive ABA services than those in large metro areas (13% and 35%, respectively; p<.01). In the majority of cases, the cost of ABA services was free or minimal (74%) and was funded and/or provided by the public school (48%) or Early Childhood programs (26%).

Conclusions:

Living outside of a large metro area may delay ASD diagnosis and limit access to specialized schools and services, but may promote more inclusive education. Future research will examine national trends.