Purpose
Routine developmental screening is essential for early identification of autism. Reliable autism screening is even more valuable for individuals from minoritized groups who are often under-detected and receive later diagnoses. Despite this importance, disparities in access to screening and accurate identification persist. Given these disparities, we were interested in examining group differences in autism screening rates at 18 and 24 months of age among children referred to Georgia’s Part C Babies Can’t Wait (BCW) program between 2018 and 2022.
Method
Among a sample of 52,282 infants and toddlers enrolled in BCW, as hypothesized males and children with private insurance had higher screening likelihoods compared to females and children with public insurance.
Results
Unexpectedly, Black and Hispanic children were more likely to be screened than their counterparts. To examine this further, an examination of screening timing revealed that White and male children were more likely to be screened before their referral to BCW compared to peers.
Conclusion
This reveals continued inequities in screening timing but suggests that BCW providers serve an important role in identifying children who may have been missed in other settings.
From the article:
Using a large sample of families participating in state-funded EI, the current study documented continued sociodemographic variability in terms of autism screening rates and the timing of autism screening among young children. The first research question focused on who received screening and the second research question focused on timing differences within children who were screened. In alignment with previous research (Eldeeb et al., 2023; Evans et al., 2018; Kuhn et al., 2021), we found that males and children from families with private insurance were more likely to be screened at either 18- or 24-months compared to females and families that did not report having private insurance. In this dataset, we observed a higher prevalence of autism screening rates among Black children compared to White peers, and Hispanic children compared to non-Hispanic children. More specifically, within this dataset, Black and Hispanic males living in metropolitan settings were more likely to be screened compared to White and non-Hispanic peers. This finding contradicts past research showing inequities in screening rates among racially and ethnically diverse children (Aylward et al., 2021; Carbone et al., 2020; Hirai et al., 2018; Mandell et al., 2009; Wiggins et al., 2020). To further explore the current dataset, among those with screening data we examined if this date was before or after their enrollment into BCW. It was revealed that the unique racial finding indicated an underlying screening disparity in regard to timing. Among the subset of children screened, we observed that White children were significantly more likely to be screened before enrollment in EI (BCW), whereas Asian, Native American and Alaskan, and Black children were more likely to be screened after entry into BCW. These data highlight that delays in screening are still prominent for some minoritized groups but also demonstrate how community agencies can help ensure universal screening across groups.
Early screening of autism primarily falls under the jurisdiction of primary care physicians engaging in early well visits (Coury et al., 2017). Previous research has documented that autism screening is not equitable across practices. For example, pediatricians with high rates of patients with Medicaid have very low rates of autism screening (Arunyanart et al., 2012). The sociodemographic differences observed in this study reveal the continued prominence of screening disparities among minoritized racial and ethnic groups in these traditional screening settings. This also aligns with research from minoritized communities documenting a lack of support from primary care physicians (Horiuchi et al., 2023; Mendoza et al., 2024), which leads to the need to advocate with greater fervor to receive care equitable to peers. Given these persistent sociodemographic screening discrepancies in primary care settings (Wallis, 2021), other community providers are being called upon to help fill the early autism screening gap (Fein et al., 2017; Nowell et al., 2015). In this study, the higher screening rates within BCW for Black and Hispanic children not previously screened highlight the crucial role EI providers can play in improving screening disparities. These study findings align with the documented gap that Spanish-speaking Latine parents often encounter between when they first voice their concerns and the actual age of diagnosis (Wallis et al., 2022).
The finding in this study that autism screening more readily occurred in males compared to females aligns with much of the existing literature (Eldeeb et al., 2023; Evans et al., 2018). These persistent findings reflect the bias to more readily notice autism in children representing the White male autism phenotype (Cruz et al., 2024; D’Mello et al., 2022). Thus, more research must focus on better understanding the female autism phenotype and how it may be overlooked using current screening and diagnostic assessment practices (Napolitano et al., 2022). For example, autistic females may have strengths in their social-communication skills and have a higher tendency to mimic and imitate social skills when compared to autistic males, which might result in hesitancy to deem screening necessary (Head et al., 2014).
Of note, geography or urbanicity also played a meaningful role in our findings. Children from rural areas were more likely than those from metropolitan areas to be screened before BCW and children from micropolitan areas were less likely to be screened before entry into BCW (e.g., screened later than children in metropolitans). The difference between metropolitan and micropolitan areas aligns with previous research showing a higher prevalence of autism rates in urban areas of the United States that likely have a high density of university-medical centers, such as Atlanta, Georgia (Bradshaw et al., 2024). This is likely due to differences in proximity to qualified providers, available resources at the county level, and other sociodemographic factors that are often associated with rural settings (e.g., education level and race; Bradshaw et al., 2024; Vanegas et al., 2023). The finding that children from rural areas were being screened earlier than metropolitan areas was less expected. Research documenting close relationships between rural doctors and patients might serve as one potential explanation for this finding (Desjarlais-deKlerk & Wallace, 2013) but this does not align with the majority of the published data (Antezana et al., 2017).
Families with lower incomes have documented disparities in accessing a myriad of treatments (Smith et al., 2020) and assessment services (Zuckerman et al., 2014). Similar to past research documenting diagnostic disparities tied to public insurance (Kuhn et al., 2021), in this study, children from families reporting having private insurance were more likely than those that did not report it to be screened. General factors preventing equitable care reported by families most commonly include financial stress, a limited number of available providers and resources, a lack of parent and/or provider education, and societal stigma (Aylward et al., 2021; Elder et al., 2016; Zuckerman et al., 2017), many of which have a financial component. Barriers specific to the low-income community documented in the literature include the pronounced shortage of adequate providers among households that rely on Medicaid (Aylward et al., 2021). Parents often serve a crucial role in the identification process (Raspa et al., 2015); however, documented knowledge deficits among low-income populations related specifically to the early childhood delays most related to autism also can contribute to screening delays (Campbell et al., 2019).
