Diagnosing Autism Earlier in Black Children: Reducing Delays and Bias

According to 2000-2022 data, the CDC estimates that about 1 in 31 eight-year-olds in the U.S. has been diagnosed with autism, with boys three times more likely to be diagnosed than girls. A 2020 study by Washington University also found that Black American children are often diagnosed with autism more than three years after their parents express initial concerns. This is much later than white American children, who are typically diagnosed between 18 and 24 months. These diagnostic delays by trained physicians can mean delayed interventions and poor developmental outcomes. 

There are many reasons for persistent disparities, including cultural stigma, provider bias, limited specialist access, and differences in how symptoms are interpreted across communities. Experts say early screening, family-centered communication, and proactive sharing of educational and therapeutic resources can improve access to diagnostic pathways for Black children. 

What is Autism, and How are Children Diagnosed?

Autism or autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition that affects how the brain develops. Thus, the disorder affects how a person experiences, processes, and interacts with the world. It is considered a spectrum because not every person is affected in the same way, and that is why a proper diagnosis by a medical expert is necessary. Common traits include social communication challenges, repetitive behaviors, hyper-focused interests, and sensory processing differences. 

Children are often diagnosed with ASD through general screenings at infant and toddler well-child checks, and then they are referred for specialist testing if they are not reaching developmental milestones common for their age. Specialist testing can evaluate areas such as communication, sensory responses, and motor skills. Parents play a key role throughout this process, as they know their child’s habits and behaviors best.

Why Are Black Children Often Diagnosed with Autism Later Than Their Peers?

Karen Sheridan, PhD, BCBA-D, LBA, a clinical psychologist and owner of Access Autism Testing & Consultation (AATC), shares some reasons why late diagnosis is common:

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• Non-standard pediatric approaches to autism screening: Though autism testing can begin at 18 months, some physicians take a wait-and-see approach, on the premise that children may outgrow certain habits or behaviors. Also, testing for autism is not a blood or urine test, nor a body scan. It requires persistent observation for developmental differences that parents and general practitioners may not be equipped to recognize.

• Lack of parental education: General knowledge about ASD is not provided to new parents, making it a topic that most don’t learn about until confronted with a child whose behaviors appear unruly. Often, autism symptoms are mistaken for signs of willful defiance or isolation, triggering parents to rely on disciplinary or coercive tactics rather than to seek medical support.  

• Discrimination in autism diagnoses: Even when physicians believe they’re being color-blind, they may be using outdated or racially biased depictions of how symptoms manifest. During ASD screening, clinicians may incorrectly attribute symptoms to ADHD or other conditions that are more commonly diagnosed in the Black community.

• Health insurance access: Dr. Sheridan said children on Medicaid may have a harder time getting diagnosed. “All major hospitals take Medicaid for testing, but most private providers do not take Medicaid…” This reality would limit children on Medicaid from accessing the full range of providers in their area. For rural families or those in places with already limited access to specialists, wait lists can be frighteningly long to receive a diagnosis and support.

How Does Delayed Access to Interventions Affect Long-Term Developmental Outcomes?

The educational, social, and familial challenges for a Black child with undiagnosed ASD are severe. 

Carrie Hall, PhD, Principal of Bridges Middle School, Oregon’s only middle school specifically designed for neurodivergent learners, said that “by the time some students arrive in middle school, they may have spent years struggling to understand why school feels more difficult for them than it does for their peers.” Self-confidence and academic gaps can cause personal and familial frustration. Dr. Hall said delays can keep children from accessing inclusive learning spaces that are designed to help both children and their families succeed.

Children can experience meaningful developmental gains when provided with targeted, evidence-based supports like:

• Speech-language therapy
• Occupational therapy
• Parent coaching
• Behavioral interventions
• Social communication supports

How Does Provider Bias Play a Role?

Admittedly, research data often does not include a representative sample of Black children, but implicit bias may also be at play. Dr. Hall said that “behaviors associated with autism may be more likely to be interpreted as behavioral concerns rather than developmental differences in some children of color, which can delay referrals for evaluation. Studies have also found that Black children are more likely to receive alternative diagnoses before autism is ultimately identified.” 

A 2007 study found that Black children were more likely to be diagnosed with conduct or adjustment disorders before being identified with ASD. 

Broader systemic barriers can affect how a provider engages with a family. Language differences among children, providers, and parents can severely undermine care delivery, with providers often in the best position to overcome these barriers, yet not always equipped or obligated to do so.

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Similarly, parents’ ability to make it to appointments during the workweek and to pay for out-of-network specialists or non-medical support interventions can frustrate parent-provider interactions. 

What Can Physicians Do Better?

“The use of autism screening (using measures like the M-CHAT) every six months during the toddler years should be a regular part of a pediatrician’s practice,” Dr. Sheridan said.

When autism is suspected, Dr. Hall said physicians should refer children for both a diagnostic evaluation and early intervention services simultaneously rather than waiting for one process to be completed before beginning the other. Children can begin receiving support while the diagnostic process unfolds. 

Providers should educate themselves about local autism support resources in the states where they are licensed to practice. When they know about early intervention programs, special education services, speech-language therapy, and occupational therapy centers in their area, they can share this invaluable information with families more consistently. These small changes can help improve the relationship between the physician and the caregiver throughout the lengthy and uncertain diagnosis and treatment period. 

Clinical Takeaways

• Diagnostic delays are systemic: Implicit provider bias and systemic barriers cause Black children to be diagnosed with autism over three years after parents first raise concerns. Initial misdiagnoses delay treatment and interventions.
• Compromised long-term development: Postponing autism identification prevents early access to crucial early interventions, which may lead to severe academic, social, and emotional struggles by the time children are finally diagnosed.
• Clinicians can standardize screenings: Pediatricians can improve diagnostic pathways by conducting standardized screenings every six months during toddlerhood, submitting referrals for evaluation, and providing parents with information about local resources and intervention services, even before diagnosis.

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