Suspension and Expulsion: The Data

Education, Human Rights, School Discipline, , , , ,

The reality of school discipline is more complicated than the law would suggest.  To begin with, students with disabilities, as a group, are much more likely to be suspended from school than students without disabilities.  A 2018 report, “School Climate and Safety Report” published by the Department of Education’s Office for Civil Rights found that even though only 12% of all students in the U.S. have disabilities, 26% of those subject to out-of-school suspension and 24% of those expelled have disabilities.  In other words, students with disabilities are being suspended and expelled at roughly twice the rate of other students.[1]  Students of color, especially African Americans, face even higher rates of disciplinary removal from school.  Among students with identified disabilities, roughly 9% of whites and Hispanics were suspended in any given year, while 21% of Native Americans and 23% of black students were suspended.[2]

If we look specifically at autistic students, we should remember, first of all, that there are still many autistic students who have not been formally diagnosed. Unless they happen to have another, recognized, disability, they are not protected under IDEA and may be suspended or expelled because of behavior that would be considered a “manifestation” of autism in a diagnosed student.  Since girls and minority students are much less likely than white male students to be diagnosed with autism, they are also more likely to lack IDEA protections against excessive suspensions and expulsions.[3]

Relatively little research has focused on children with an actual autism diagnosis, but a 2018 report from the Center for American Progress states that pre-school children diagnosed with autism are ten times more likely to be suspended or expelled than their “typically developing” peers.[4]  A 2017 research study analyzes data for older children in the state of Maryland, from 2004 to 2015.  The authors found that about 3.3% of both white and African American students with autism were suspended during this period.  White autistic students were much more likely that non-disabled white students to be suspended, while autistic African American students were less likely to be suspended than non-disabled African American students.[5]

The fact that both groups of autistic students this study were suspended at the same rate suggests that both groups were treated equally.  But bear in mind that African Americans are much less likely than whites to be diagnosed with autism and may instead be diagnosed with intellectual or emotional disabilities.  In the same study, 10.5% of African American students with intellectual disability had been suspended at least once, compared to only 7.3% of white students with ID.  If we assume that at least some of those diagnosed with ID also have autism, or have been misdiagnosed with ID instead of autism, then it looks like the rate of suspension for African American students with autism probably is higher than it is for whites.[6]  The authors provided no data comparing students with autism and students with “emotional disturbance,” but African-American children with autism are very frequently misdiagnosed with ED, and students with ED are the most likely of all disability groups to be suspended or expelled.  It seems plausible, then, to assume that African Americans and members of other minority groups with autism are at higher risk of being removed from school than white students with autism.

There is also the question of how often autistic students are suspended.  Sometimes schools suspend children “unofficially,” by saying they are having a “bad day” and would be better off at home.  They call the parents to pick the child up, but do not register this event as a suspension.[7]  This allows the school to get around federal regulations that limit the number of suspensions that can be imposed on students with disabilities.  As a result, suspensions from school can occur with stunning frequency.  A report on television news in Washington state looked at statewide rates of suspension and expulsion for students with disabilities, with results similar to those described above.  The main focus of the report, a young autistic man named Austin, was suspended for more than 100 days during his time in middle school (far, far beyond the 10 days a year allowed under IDEA and federal regulations).  Another young autistic man in Washington state was officially suspended for 24 days, and unofficially for 45 days, for a total of 69 days out of the classroom during a single school year.[8]  While these are extreme cases, it is not at all unusual for schools to use unofficial removals to evade the limits set on suspensions by law.

Repeated removals from school obviously limit children’s educational opportunities, leading them to fall farther and farther behind other students academically.  But beyond that, repeated suspensions and expulsion from school have devastating emotional effects on children.  As Austin, the young man mentioned in the last paragraph, put it: “I felt like I was one of the worst kids that ever was because they were just constantly sending me home.” [9]  Disciplinary removal may alienate children from schools which they see as simply not wanting them.  And so, children repeatedly suspended and expelled are much more likely to drop out of school altogether.[10]  “As a teen, I was expelled from the entire county school system and my parents had to find a private school willing to take me.  At sixteen, I dropped out of school altogether,” recalls one autistic adult.[11]

Finally, repeated suspensions and expulsion promote entry into the “school-to-prison pipeline,” especially, but certainly not exclusively, for young African American males.[12] School “resource officers” (i.e., armed police officers) often intervene in disturbances at school, all too often in inappropriate ways.  They may end up handcuffing and even bringing to jail autistic students seen as “disruptive”—setting up a vicious cycle in which these students see authorities as the enemy and act out accordingly.  In addition, many suspended and expelled students spend their days unsupervised at home or on the streets, where they may engage in a variety of criminal activities, eventually leading to arrest and imprisonment.

As research has repeatedly shown, disciplinary removal from school has no positive impact at all on student behavior.  On the contrary, it is more likely to worsen that behavior.[13]  As a result, the official policy of many school districts is that suspension and expulsion should only be used when necessary to protect other students and staff, or when guns or drugs are involved.  In practice, however, these disciplinary techniques are often used to “punish” students who skip classes, fail to complete their homework, or talk back to their teachers.  As we’ll see in the next post, autistic students who receive these punishments often view them as senseless, and even malicious (a way for “mean teachers” to get back at them).

 

 

 

 

 

 

 

 

 

 

[1] Office of Civil Rights, Department of Education, “School Climate and Safety,” 2018 report based on the 2015-16 Civil Rights Data Collection:  https://www2.ed.gov/about/offices/list/ocr/docs/school-climate-and-safety.pdf.   The disparity begins in preschool:  Cristina Novoa and Rasheed Malik, “Suspensions Are Not Support:  The Disciplining of Preschoolers With Disabilities” (Report from the Center for American Progress, January17, 2018:  https://www.americanprogress.org/issues/early-childhood/reports/2018/01/17/445041/suspensions-not-support/.  See also [No author], “Washington special needs students disciplined more than twice as often as general education peers,” report on King5 television news:  https://www.king5.com/article/news/local/washington-special-needs-students-disciplined-more-than-twice-as-often-as-general-education-peers/281-608161669.

[2] Nicholas Gage, et al., “National Analysis of the Disciplinary Exclusion of Black Students with and without Disabilities,” Journal of Child and Family Studies 28:7 (2019), 1754-64.

[3] Office of Special Education and Rehabilitative Services, “Racial and Ethnic Disparities in Special Education:  A Multi-Year Disproportionality Analysis by State, Analysis Category, and Race/Ethnicity” (2016), pp. 23-24:  https://www2.ed.gov/programs/osepidea/618-data/LEA-racial-ethnic-disparities-tables/index.html.

[4] Cristina Novoa and Rasheed Malik, “Suspensions Are Not Support:  The Disciplining of Preschoolers With Disabilities” (Report from the Center for American Progress, January17, 2018:  https://www.americanprogress.org/issues/early-childhood/reports/2018/01/17/445041/suspensions-not-support/.

[5] M. Krezmien, et al., “Suspension Rates of Students with Autism or Intellectual Disabilities in Maryland from 2004 to 2015,” Journal of Intellectual Disability 61:11 (November, 2017), 1011-1020

[6] M. Krezmien, et al., “Suspension Rates of Students with Autism or Intellectual Disabilities in Maryland from 2004 to 2015,” Journal of Intellectual Disability 61:11 (November, 2017), 1011-1020.

[7] Robert Tudisco, “Can the School Give my Child With an IEP ‘Unofficial” Suspensions?’”, on the Understood.org website:  https://www.understood.org/en/school-learning/your-childs-rights/basics-about-childs-rights/can-the-school-give-my-child-with-an-iep-unofficial-suspensions; see also Cristina Novoa and Rasheed Malik, “Suspensions Are Not Support:  The Disciplining of Preschoolers With Disabilities” (Report from the Center for American Progress, January17, 2018:  https://www.americanprogress.org/issues/early-childhood/reports/2018/01/17/445041/suspensions-not-support/.

[8] Report from the Washington State ACLU, “Pushed out; kicked out: Stories from families with special education students in Washington”:  https://www.aclu-wa.org/pages/pushed-out-kicked-out-stories-families-special-education-students-washington.

[9] [No author], “Washington special needs students disciplined more than twice as often as general education peers,” report on King5 television news:  https://www.king5.com/article/news/local/washington-special-needs-students-disciplined-more-than-twice-as-often-as-general-education-peers/281-608161669.

[10] Amity Noltemeyer, Rose Marie Ward, and Caven Mcloughlin, “Relationship Between School Suspension and Student Outcomes: A Meta-Analysis,” School Psychology Review 44 (2015), 224-40; Susan Faircloth, “Factors Impacting the Graduation and Dropout Rates of American Indian Males with Disabilities,” in Susan Faircloth, Ivory Toldson, and Robert Lucio, eds., Decreasing Dropout Rates for Minority Male Youth with Disabilities from Culturally and Ethnically Diverse Backgrounds (Clemson, SC:  National Dropout Prevention Center for Students with Disabilities, 2014), pp. 8-9.

[11] Max [formerly known as Sparrow Rose] Jones, No You Don’t:  Essays from an Unstrange Mind (Self-published, 2013), p. 51

[12] Abigail Novak, “The association between experiences of exclusionary discipline and justice system contact: A systematic review,” Aggression and Violent Behavior 40 (2018), 73-82; Amity L. Noltemeyer, Rose Marie Ward, and Caven Mcloughlin, “Relationship Between School  Suspension and Student Outcomes:  A Meta-Analysis,”  School Psychology Review  44: 2,  (June,  2015):  224-24; A.E. Cuellar and S. Markowitz, “School Suspension and the School-to-Prison Pipeline,” International Review of Law and Economics 43 (2015), 98-106.

[13] Ambra Green, Deanna Maynard, and Sondra Stegenga, “Common misconceptions of suspension: Ideas and alternatives for school leaders,” Psychology in the Schools 55:4 (April, 2018), 419-28.

Removal from School for Disciplinary Reasons: The Law

Education, Human Rights, School Discipl, School Discipline, ,

My apologies for all the legal stuff that follows.  Understanding how suspension and expulsion can legally be imposed on autistic children requires understanding the complicated provisions concerning student discipline laid out in the Individuals with Disabilities Education Act (IDEA), as amended in 1997 and 2004.

In the United States, under the current, amended form of IDEA, not only are children with autism and other disabilities entitled to FAPE (a free, appropriate, public education, in the least restrictive environment possible), but school actions that might deny them FAPE by removing them from the classroom are subject to legal limitations.[1]  The school must be very careful about removing a child temporarily (suspension) or permanently (expulsion), if the child’s behavior is a “manifestation” of her or his disability—that is, the behavior is caused either by the disability itself, or by the school’s failure to carry out the child’s IEP plan.  For example, if a child gets into trouble for not doing what the teacher says, and if it turns out that the child has an auditory processing disorder which makes it difficult or impossible to hear what the teacher is saying, and if the accommodations for auditory processing disorder written into her or his IEP have not been fully implemented, then the school cannot suspend or expel the child.

The school also cannot use removals from the classroom in ways that turns them into an unofficial “change of placement” to a more restrictive environment.[2]  If the school does want a change of placement, it is supposed to follow a formal review process, showing that the school has done all that it can to offer the student accommodations and teach him or her “better” behaviors, without success.  But because these actions present a major obstacle to their child receiving FAPE, parents who know their child’s rights can and do appeal school decisions through the state education system and possibly in court.

Schools use both in-school suspensions, in which a child is removed from the classroom but remains in the building, and out-of-school suspensions, in which a child is normally sent home, to punish unwanted behaviors.  According to federal regulations, a disabled child cannot be suspended in either setting for more than ten consecutive school days in response to a particular incident.  If the school wants to suspend a child for a longer period of time, it must provide appropriate educational and additional IEP services, at the school or at home, so that the child can continue to receive an education.  The school must also hold a “manifestation determination review” to decide whether the child’s unwanted behavior or behaviors is a “manifestation” of their disability. If they conclude that it is, additional efforts must be made to modify the child’s behavior.  The school is required to review his or her Individualized Education Program (IEP) to ensure that it is being fully implemented, possibly conduct a first or a new Functional Behavior Analysis (FBA) to determine why the child is “misbehaving” in the first place, and then find ways to teach the student “better” behaviors, while keeping her or him in the classroom.[3] 

Even for students whose behavior is determined to be a “manifestation” of their disability, there are exceptions to the “ten day” rule.  Under certain circumstances—involving guns, drugs, or serious violence against another person—a student may be removed from the school for up to 45 days, as long as educational services continue to be provided in an “interim alternative educational setting.”[4]  The law does not specify what this term refers to—it simply says that the child should continue to receive educational services while in this setting.  Under some circumstances and in some places, children may be sent to special programs run by the school district, but located away from the school itself.  Under other circumstances, children may be sent to juvenile detention centers, residential treatment centers, or even psychiatric hospitals.  There are educational opportunities at these places, but they are—to say the least—extremely limited.

Even without guns or drugs or violence being involved, schools can legally suspend autistic students more than once a year, so long as educational services continue to be provided.  But if a school repeatedly suspends a child, as punishment for the same or similar behaviors, then it is moving into dangerous legal territory.  Repeated suspensions (even if each one is no more than ten days in length), create a “pattern” of administrative behavior that begins to look like an unstated change of placement (a denial of FAPE).  Federal regulations warn schools not to suspend a student with disabilities for the same or similar behaviors for more than 10 days over the course of a single school year, because this begins to look like a change of placement. [5]  If there are more than ten days of suspension during the year, the school district determines whether the suspensions constitute a change of placement, on a case-by-case basis– but parents have the right to appeal to the courts on the grounds that their child is not receiving FAPE.

If a school decides it wants to expel an autistic child, the IEP team must hold a manifestation determination review within 10 days after the decision is made.  If the child’s behavior is found to be a manifestation of autism, then the child cannot be expelled.  If the behavior is not found to be a manifestation of disability, parents have the right to call for a due process hearing, in which the IEP team’s decision will be reviewed by a hearing officer.  Depending on the state, there may be a one- or a two-tiered system—in the former, the case is heard by a state hearing officer, in the latter, the case is heard first by an officer from the school district, and then (if the parents decide to appeal) by a hearing officer from the state.  If the parents are still not satisfied, they can bring a civil law case against the school district.

This is the law as laid out in the amended text of IDEA and in federal regulations.  Disabled students’ rights to a free, appropriate, public education must be protected.  Unfortunately, though, far too many school districts do actually find ways of removing “troublesome” students without considering whether the “troublesome” behaviors are manifestations of the students’ disabilities, and without following the procedures required by law.  I will discuss some of these practices in my next post.

[1]  IDEA, part B, subpart E, sections 300.530-300.536: https://sites.ed.gov/idea/regs/b/e.

[2]  IDEA, part B, subpart E, section 300.536

[3] IDEA, part B, subpart E, section 300.530.

[4] IDEA, part B, subpart E, section 300.530.

[5] Code of Federal Regulations, 2005.  Title 34:  Education.  Section 300.536, “Change of Placement Because of Disciplinary Removals.”  This regulation was added to the Code in 2005, to clarify the 2004 amendment of IDEA.

Civil Rights for Nonspeakers — Ido in Autismland

Uncategorized, ,

The traditional term for not speaking is ‘dumb.’ That says it all. If someone can’t talk then they are ‘dumb.’ I am dumb, apparently. The thesaurus offers these synonyms for dumb: among them mute, speechless, silent, and then fifty additional synonyms for stupidity, including the colorful pinheaded and dim-witted. The bias equating intelligence with speech…

Civil Rights for Nonspeakers — Ido in Autismland

Diagnosis and Discipline

Autism Diagnosis, Education, , , , ,

For a student with autism, diagnosis is always a double-edged sword.  On the one hand, an official diagnosis may result in access to services such as ABA (for good or ill), speech therapy, occupational therapy, physical therapy, etc.; and for accommodations at school such as classroom aides, extended time on tests, access to quiet rooms, etc.  It offers some legal protections against suspension or expulsion from school.  At the same time, autism obviously carries a profound stigma in American society.  In school, the child who has an autism diagnosis is often regarded by administrators, teachers and staff as different and potentially dangerous.  Non-verbal autistics are usually assigned to special education classrooms, or even separate schools, where they usually receive only a limited academic education, regardless of their actual intelligence and potential.  And despite privacy rules, autistic children’s diagnoses far too often become known to their fellow students, resulting in bullying.

Many parents are aware of these problems, and struggle with deciding what is best for their child, or sometimes what is best for the parents themselves, or for the rest of the child’s family.  Should they seek a diagnosis or not?  And if they do receive a diagnosis from a doctor or psychologist, should they share it with the school?  Does their child’s need for services, accommodations, and protection outweigh the potential impact of stigma?  But parental anxiety about stigma is only one of many factors affecting whether a child is diagnosed.  Sex, socio-economic status, race/ethnicity, immigrant status, language and cultural differences, and even the place where a child lives, all play a role in determining who will be diagnosed and who will not.

“Four times as many boys as girls have autism.”  This has been repeated so often that it may be treated as a simple fact.[1]  But the correct formulation should actually be that “four times as many boys as girls receive autism diagnoses.”  We simply don’t know how many girls have autism.  What we do know now, though, is that many girls on the spectrum remain undiagnosed because parents, psychologists and pediatricians don’t know what autism looks like in girls.[2]   For example: parents and care-givers are more likely to become concerned and more likely to seek a professional diagnosis when children engage in “externalizing” (aggressive) behaviors.  But because girls are less likely than boys to behave aggressively, parents may not realize the extent to which they are “different” from other children, and as a result, their daughters may not be tested for autism until they reach school age or even beyond.[3]  In addition, most parents and professionals still don’t realize that autistic girls are better at “camouflaging” or “passing” than autistic boys, because they are likely to imitate the behavior of those around them (even if they don’t understand the reasons for that behavior), whereas boys are more likely to simply withdraw from social interactions altogether.[4] The standard diagnostic criteria for autism present additional problems.[5]  Engagement in repetitive behaviors has long been a key criterion.  But autistic girls are less likely to engage in repetitive behaviors than boys—and even when they do, these behaviors may appear at first glance to be normal for young females.  Autistic girls may collect dolls or devote lots of time to coloring pictures.  What parents and the professional responsible for diagnosis often don’t realize is that these girls are not playing with the dolls, but rather lining them up according to the color of their dresses; they are filling their coloring books with intricate patterns that have little to do with what’s going on in the pictures.[6]  As a result of these and other factors, girls are generally diagnosed at a later age than boys, and may remain undiagnosed into adulthood, even when they are quite severely affected by autism.”[7]

Coming from a poor family also makes it less likely that an autistic child will receive a diagnosis.  As one study found:  “ . . . the proportion of children in poverty receiving services or supplementary income because of ASD was lower than the proportion expected on the basis of estimates of the prevalence of ASD in the general population.”[8]  While autism diagnoses have increased rapidly in recent years, the increase has been much lower for the poor than for other income groups.[9]  This is almost certainly because access to health care (and therefore medical sources of diagnosis) is much more limited for the poor in the United States, than for the middle and upper class.  In countries with universal health care, such as Sweden and France, such differences do not exist.[10]

Children of color are less likely than white kids to be diagnosed with autism.  They are also more likely than white kids to be diagnosed late (after they have started school), or simply mis-diagnosed as having emotional or behavioral problems. The time from when parents become concerned to when the child receives an official diagnosis (if they ever do) is significantly longer for children of color than for whites.  Even when socio-economic status and levels of parental education are factored in, these disparities remain.  Among children of color, those most likely to be diagnosed are those with lower (or apparently lower) IQs, while those with the “milder phenotype” of autism (what used to be called Aspergers syndrome) remain under-identified. Fewer children of color receive early intervention services (such as ABA or TEACCH) for autism, and when they do receive services, it is generally for fewer hours a week. Once they reach school age, they are more likely than white kids to be identified as having “behavior problems” and are over-represented in school services targeting behavior (as opposed to social skills or learning techniques). [11]  High levels of poverty in these communities, as well as prejudice, contribute to these disparities.  Racial disparities in diagnosis and services affect all non-white children, but some groups—especially Hispanics and African-Americans—are more seriously affected than others.

Immigrant families may be poor and they may belong to racial or ethnic minorities, but they also face problems in receiving accurate diagnoses for their children simply because they are immigrants.  Language differences can be a significant barrier, because so many of the diagnostic tools for autism are based on instruments originally written in English, and perhaps unavailable in, or poorly translated into, other languages.  (Some immigrants may also be unable to read or write.)  Lack of familiarity with American medical and educational systems may play a role, as do those systems lack of familiarity with other cultures.  For example:  many American practitioners view a child who is unwilling to make eye contact with them as potentially autistic.  However, in many immigrant communities, children are taught that it is rude to look directly into an adult’s eyes.  Some of the testing used to detect autism looks at children’s interactions with toys—but immigrant children may have never seen the toys presented to them, and may have no idea how to play with them “appropriately.”[12]  It is also possible that cultural differences may shape an immigrant family’s decision to seek a diagnosis. One study found that Korean-American families in New York City were often reluctant to seek diagnosis (or even discuss autism with others), because of the shame having a disabled child might bring on their family.[13]  This, and other similar studies, must be treated with caution, however, because they tend to be based on interviews with a very small sample of people, who may not be representative of the group as a whole.  However, it is certainly possible that cultural differences play a role in immigrant families’ decision to seek a diagnosis.

Finally, there is the question of whether families who want a diagnosis and who have enough resources to get one can find someone to provide it.  Other things (wealth, English language competency, etc.) being equal, it is not very difficult to find a doctor or psychologist able to diagnose autism in most of America’s big cities.  However, one recent, if somewhat controversial, study, has identified a multitude of “diagnosis deserts,” especially in rural or thinly populated parts of the United States.  80% of U.S. counties have no autism diagnostic clinics.[14]  Families from these areas have to either travel long distances to find a qualified diagnostician, or wait until their children are old enough to receive diagnoses and services from local school systems.

Disparities in the ability to get an autism diagnosis are significant, and they have significant implications as well.  In my next post I will concentrate on just one issue—the impact of having/not having an autism diagnosis on school discipline.

[1] E.g., “What is Autism Spectrum Disorder,” Center for Disease Control and Prevention website (current):  https://www.cdc.gov/ncbddd/autism/facts.html;  Deane Morrison, “Why Autism Strikes Mostly Boys,” University of Minnesota’s Office of the Vice-President for Research’s website (November 27, 1917): https://research.umn.edu/inquiry/post/why-autism-strikes-mostly-boys;

[2] Sylvie Goldman, “Sex, Gender, and the Diagnosis of Autism—A Biosocial View of the Male Preponderance,” Research in Autism Spectrum Disorders 7 (2013), 675-679; Lauren Little, et al., “Do early caregiver concerns differ for girls with autism spectrum disorders?” Autism: The International Journal of Research and Practice 21 (2017), 728-32;

[3] Jorieke Duvocot, et al., “Factors Influencing the Probability of a Diagnosis of Autism Spectrum Disorder in Girls versus Boys,” Autism: The International Journal of Research and Practice 21 (2017), 646-58.

[4] Rachel Hiller, Robyn Young, and Nathan Weber, “Sex Differences in Pre-Diagnosis Concerns for Children Later Diagnosed with Autism Spectrum Disorder,” Autism: The International Journal of Research and Practice 20 (2016), 75-84.

[5] Although this view remains somewhat controversial.  Compare two recent articles in Spectrum News:  Nicholette Zeliadt, “Diagnostic Tests Miss Autism Features in Girls” (May 13, 2017): https://www.spectrumnews.org/news/diagnostic-tests-miss-autism-features-girls/; and Hannah Furfaro, “Diagnostic tests don’t miss girls with autism, study suggests”: https://www.spectrumnews.org/news/diagnostic-tests-dont-miss-girls-autism-study-suggests/.  It is worth noting, however, that the study described in the second article looked at girls already diagnosed with autism—which undermines its main point.

[6] Rachel Hiller, Robyn Young. and Nathan Weber, “Sex Differences in Autism Spectrum Disorder Based on DSM-5: Evidence from Clinician and Teacher Reporting,” Journal of Abnormal Child Psychology 42 (2014), 1381–1393.

[7] Rachel Hiller, Robyn Young, and Nathan Weber, “Sex Differences in Pre-Diagnosis Concerns for Children Later Diagnosed with Autism Spectrum Disorder,” Autism: The International Journal of Research and Practice 20 (2016), 75-84.

[8] Maureen Durkin, et al., “Autism Spectrum Disorder Among US Children (2002–2010): Socioeconomic, Racial, and Ethnic Disparities,” American Journal of Public Health 107:11 (2017), 1818-1826.  See also Pauline Thomas, et al., “The Association of Autism Diagnosis with Socioeconomic Status,” Autism:  The International Journal of Research and Practice 16:2 (March, 2012), 201-13.

[9] C.D. Pulcini, et al., “Poverty and Trends in Three Chronic Disorders,” Pediatrics 139:3 (March, 2017).

[10] Maureen Durkin, et al., “Autism Spectrum Disorder Among US Children (2002–2010): Socioeconomic, Racial, and Ethnic Disparities,” American Journal of Public Health 107:11 (2017), 1818-1826.

[11] Amber Angell, et al., “A Review of Diagnosis and Service Disparities Among Children with Autism from Racial or Ethnic Minority Groups in the United States,” International Review of Research in Developmental Disabilities 55 (2018), 145-80.  See also Jason Travers and Michael Krezmien, “Racial Disparities in Autism Identification in the United States During 2014,” Exceptional Children 84 (2018), 403-19.  Travers and Kremien pay special attention to differences between states in racial disparities; these differences can be quite significant.

[12] Emily Sohn, “Why Autism Seems to Cluster in Some Immigrant Groups,” Spectrum News, 11/29/17.

[13] Christina Kang-Yi, et al., “Influence of Community-Level Cultural Beliefs about Autism on Families’ and Professionals’ Care for Children,” Transcultural Psychiatry 55 (2018), 623-47.  But compare the following three studies, each of which comes to a different conclusion about Mexican immigrant mothers’ attitudes towards autism: Elizabeth Ijalba, “Hispanic Immigrant Mothers of Young Children With Autism Spectrum Disorders: How Do They Understand and Cope With Autism?” American Journal of Speech-Language Pathology 25 (2016), 200-13;  Shana Cohen and Jessica Miguel, “ Amor and Social Stigma:  ASD Beliefs Among Immigrant Mexican Parents,” Journal of Autism and Developmental Disorders 48 (2018), 1995-2009; Brenda Barrio, et al., “The Impact of Culture on Parental Perceptions about Autism Spectrum Disorders:  Striving for Culturally Competent Practices,” Multicultural Learning and Teaching 14 (2019), 1-9.

[14] Hannah Furfaro, “New Autism Map Points to Diagnostic Deserts in United States,” Spectrum News, 8/28/19: