1. Racial differences in the symptom profiles of children assessed for Autism Spectrum Disorder Kimberlee Krubinski Kristi Guest, Ph.D., Caroline Leonczyk, M.A. Olivio Clay, Ph.D, & Sarah O’ Kelley, Ph.D, The University of Alabama at Birmingham This research is supported in part by grants from Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCH) Leadership Education in Neurodevelopmental and Related Disabilities (LEND) and the Combating Autism Act Initiative (CAAI). Conflict of Interest: None.

2. Abstract Past research on racial differences in symptoms of autism spectrum disorders (ASD) has been inconsistent. This study looks to identify differences between African American and Caucasian not of Hispanic/Latino ethnicity children’s symptoms presented during the Autism Diagnostic Observation Schedule (ADOS). Participants included 365 children referred to the UAB Civitan-Sparks Clinics due to a question of developmental delay who received a comprehensive autism evaluation using the ADOS. Results indicated that among minimally verbal children, African American children had poorer social interaction scores, less frequent directed vocalizations, and a greater incidence of tantrums during the ADOS. No differences were observed between African American and Caucasian children with phrase speech. Among verbally fluent children, African American children offered information about themselves less frequently during the ADOS. The knowledge of how autism symptoms present differently between races could aid in earlier identification in African American children, who currently have a delayed age of identification.

3. Introduction African American children with ASD have been reported to have: – Greater deficits in spoken language skills 1,4,7 – Increased levels of aggressive behaviors 2 African Americans have a cultural tendency to look at lower areas of the face, rather than the eyes, when conversing 3 Caucasians have been shown to have a higher prevalence of restricted interests 4 Other studies have indicated no racial differences in the general symptom categories of ASD 6 Research has identified that socioeconomic status 6, gender 5, and age 1 impact the presence and type of symptoms of ASD presented

4. Gaps in Knowledge There has been minimal research examining: Racial differences in specific symptoms of ASD Racial differences in other behavioral symptoms observed during autism assessments Racial differences in symptoms observed on the gold standard diagnostic tool (ADOS) Comparisons between specific racial groups (i.e., African American vs. Caucasian, rather than minority vs. nonminority) Among the research that has been conducted, there is conflicting evidence in regards to racial differences.

5. Aims & Hypotheses This study seeks to examine the differences in ASD symptomatology between African American and Caucasian children referred for an autism evaluation, regardless of their final diagnosis. It is predicted that: – African American children with evidence more social interaction difficulties during the ADOS across all ages/language levels (i.e., all ADOS modules) – African American children will have more difficulties in language and communication during the ADOS across all ages/language levels – Caucasian children will have more frequent repetitive behaviors across all ages/language levels

6. Methods: Participants Data was obtained via retrospective file review from a tertiary care clinic at a university-based interdisciplinary ASD clinic N=365 (Age range 1-17, mean 4.98 years)

7. Methods Participants received a comprehensive ASD evaluation from experienced clinicians using the Autism Diagnostic Observation Schedule (ADOS) and typically the Autism Diagnostic Interview Revised (ADI-R). These are the gold standard assessments for clinical diagnosis of ASD. Children received different ADOS modules based on their age and language level: – Module 1: No or limited speech (n=177) – Module 2: Some or Few phrases of speech/scores split by over or under the age of five (n= 69) – Module 3: Fluent or proficient speech (n= 66) Code 0 is used "when the behavior shows no evidence of abnormality.“ Code 1 is used "when the behavior is mildly abnormal or slightly unusual, but not necessarily grossly abnormal.“ Code 2 is used "when the behavior is definitely abnormal in the way specified.“ Code 3 is used "when the behavior is markedly abnormal in a way that interferes with the interview, or when the behavior is so limited that judgments about quality are impossible.” Code 7 or 8 when the item is not applicable for testing. These items were removed. *Higher scores are related to poorer behaviors and/or more significant ASD symptoms*

8. Methods: Analysis Cronbach’s alpha tests were run within each module to identify similarities between each item in the ADOS by symptom category (cut off α of.8) – Social interaction (i.e., unusual eye contact, quality of social response) – Language and communication (i.e., immediate echolalia, stereotyped/idiosyncratic use of words or phrases) – Behavioral symptoms (i.e., self-injurious behavior, hand/finger and other complex mannerisms) Independent Sample T-tests were run to identify differences in ASD symptoms between African American and Caucasian participants. A linear regression model was run to identify the impact of socioeconomic status, gender, age, and comorbid behavioral disorders on ASD symptomatology.

9. Results: Cronbach’s alpha ADOS Symptom Categories ADOS Scores Module 1Module 2Module 3 Language and Communication 0.874*0.780.691 Social interaction 0.913*0.899*0.875* Behavioral 0.320.520.038 Figure 1. Cronbach’s alpha reliability tests identified that items in the social interaction category for Module 1, 2, and 3 tested for statistically related aspects of behavior and skills, as well as the items in the language and communication category for Module 1. These categories were tested as a whole to identify racial differences for broad symptom categorization, as well as tested as individual items for specific differences. The remainder of the items were tested as separate items.

10. T-Tests for Symptom Categories T= -2.376, p=.019T= -2.959, p=.005 * All other group comparisons were not significant*

11. T-tests for Module 1 ADOS Items White not Hispanic/Latino

12. T-tests for Module 3 ADOS Items

13. Results: Other Findings No statistically significant racial differences were found in any items in Module 2. None of the hypothesized confounding variables were shown to impact ADOS Symptomatology.

14. Discussion Consistent with the findings of Horovits and colleagues (2011) using the Baby and Infant Screen for Children with Autism Traits Part 3, our study indicates that African American children may show greater difficulties in social interaction and communication as well as more frequent tantrums/aggressive behaviors during autism assessments. Racial differences are primarily in the language and communication symptoms; thus, there is a stronger need for early intervention focus and caregiver focus on language skills in the African American children in order to best serve this population. Racial differences in symptoms were very dependent upon the Module; however, this could be due to lower numbers of children who were eligible for Module 2 and Module 3. One limitation of the study is the use of clinician report of race, rather than parent, due to the clinical setting. However, medical records were used when available to help ensure valid measurement.

15. Conclusions This study highlights the higher prevalence of language and communication difficulties observed in certain African American children evaluated for ASD in a tertiary care clinic. Having the knowledge of how autism symptoms present differently between races could aid in earlier identification in African American children, who currently have a delayed age of identification. This could also improve information for awareness campaigns focused on increasing early identification across racial groups. Appropriate identification impacts the ability of clinicians to recommend services as well as for researchers to develop more culturally appropriate services based off of higher symptom prevalence.

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