Accuracy of ASD Diagnoses in a Sample of Black and Hispanic School-Aged Children

Background:  Recent prevalence estimates from the Center for Disease Control (CDC) indicate that the rate of autism spectrum disorder (ASD) has risen disproportionately in Black and Hispanic populations, with 110% and 91% increases respectively. While better diagnostic practices and increased awareness may account for part of this increase, it remains unclear whether there is truly an epidemic in these populations or whether misdiagnosis or over-diagnosis may contribute to current prevalence estimates.  Results from recent studies are mixed, with some indicating minorities are less likely to be diagnosed with ASD, and others considering minority status an additional risk factor. Further research is needed to better understand the presentation of ASD in minority populations. 

Objectives:  (1) To establish the diagnosis of ASD using gold-standard practices in an ethnically and racially diverse population of children who were previously diagnosed with ASD through community or educational resources. (2) To determine whether specific risk factors, either alone or in combination, can predict ASD diagnosis in this population.

Methods:  Sixty children between the ages of 5 and 12 presented to the Seaver Autism Center at Mount Sinai for autism-focused diagnostic evaluations as part of ongoing studies examining evidence-based practices to improve the health and well-being of Black and Hispanic children with ASD. Sixty percent of the sample (n=36) presented with a previous diagnosis or IEP classification of ASD. All participants received comprehensive gold-standard evaluations, including a psychiatric evaluation, the Autism Diagnostic Observation Schedule (ADOS-2) and the Autism Diagnostic Interview-Revised (ADI-R). ASD diagnoses were based on consensus diagnosis and DSM-5 criteria.

Results:  Twenty-eight percent of the sample identified their child as Black, 47% as Hispanic, and 25% as both Black and Hispanic. Of the 36 children presenting with a past diagnosis of ASD, approximately 70% (n=25) of diagnoses were confirmed and 30% (n=11) did not meet criteria for an ASD diagnosis.  Of the 25 cases with confirmed ASD, 16% (n=4) also received a diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD). Among the 11 cases previously diagnosed with ASD who did not meet criteria according to our consensus diagnosis, 82% (n=9) received a diagnosis of ADHD. Both groups endorsed multiple risk factors for ASD, including perinatal complications, admission to the neonatal intensive care unit (NICU), and delays in motor and language development. There were no significant differences between groups in the number or type of risk factors reported.

Conclusions: Our results suggest that there is a proportion of Black and Hispanic children who carry a diagnosis or classification of ASD whose symptoms may be  better explained by other diagnoses. Within our sample, clinically significant ADHD symptoms were present in all but two participants whose ASD diagnoses were not confirmed through gold-standard evaluation. Future studies must explore ways to enhance diagnostic practices in community-based and educational settings to improve accuracy of diagnoses and to ensure optimal treatment. Given the high prevalence of risk factors found across groups in this study, it is important to continue examining risk factors in larger samples of ethnically and racially diverse children.