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    School Psychology Review, 2013, Volume 42, No. 3, pp. 298-316 Children, Research, and Public Policy School-Based Autism Identification: Prevalence, Racial Disparities, and Systemic Correlates Amanda L. Sullivan University of Minnesota Abstract. This study examined prevalence and relative risk of school-based autism identification by race, and the relations of each to state characteristics. The sample was drawn from general and special education enrollment data for students ages 21 in 46 states during the 2008-2009 academic year. The results show that 1 in 228 students nationwide was identified with autism for special education eligi- bility, but there was substantial variability across states, with some states nine times more likely to identify students with autism than others. There were significant differences in prevalence between racial groups at the state level Hispanic and American Indian/Alaskan Native students were often less likely to be identified with autism relative to White students, whereas Asian/Pacific Is- lander students were commonly more likely to be identified with autism than White students. Regression analysis indicated systemic predictors of prevalence and minority relative risk varied. Implications for research, practice, and policy are discussed. Public awareness of autism has esca- lated in recent years along with alarm about rapidly rising prevalence estimates. Autism is viewed as a national public health concer with an estimated national cost of $90 billion annually, which led to the passage of Combat- ing Autism Act of 2006 to coordinate research and service activities across nine federal agen- cies (Office of Autism Research Coordination [OARC}, 2010). Schools are increasingly challenged to meet the needs of these students, but there has been less attention within the empirical literature to school-based identifica- tion of autism, and even less consideration of racial disparities. Yet appropriate identifica- tion is critical because of the utility of early intervention and the necessity of special edu- ci eligibility to receive individualized ser- vices in schools (Eldevik, Hastings, Hughes, Jahr, Eikeseth, & Cross, 2009; Reichow, 2012). Further, racial disparities in identifica- tion and treatment in other areas of special Correspondence regarding this article should be addressed to Amanda Sullivan, University of Minnesota, Educational Psychology, 250 Education Science Bui e-mail: asulliva@umn.edu ing, 56 E. River Road, Minneapolis, MN 55455; 298 School-Based Autism Identification education are well documented and have in- formed federal and state policy (Albrecht, Skiba, Losen, Chung, & Middelberg, 2012; Donovan & Cr 2002; Ford, 2012). The present study examined (1) prevalence of au- tism in special education, (2) racial differences in autism prevalence among children and youth identified for special education, and (3) the relations of prevalence and relative risk to state characteristics. Autism Spectrum Disorders Autism spectrum disorders (ASD) refer to a cluster of neurodevelopmental disorders characterized by impairments in communi tion, social skills, and behavior. Within ASD, autism refers to a particular neurodevelopmen- tal condition presented as severe deficits in communication, social skills, and repetitive or restrictive behaviors or interests (American Psychiatric Association, 2000). Although the etiology of this disorder and ASDs more broadly is not fully understood, it is believed they are affected by numerous genetic and environmental factors influencing brain devel- ‘opment (Levy, Mandell, & Schultz, 2009). Mounting evidence indicates that chil- dren can be reliably diagnosed with autism by age 2 (Eaves & Ho, 2004; Matson, Wilkins, & Gonzalez, 2008) and that early intervention results in significant improvement in function- ing (e.g., Dawson et al., 2010; Eldevik et al., 2009; Reichow, 2012). As such, scholars en- courage early identification in order to foster appropriate intervention, educational pro- gramming, and family support (Filipek et al., 2000). Not surprisingly, school systems are increasingly charged with responding to the needs of these children and their families, and school psychologists are frequently involved in diagnosis and educational planning for stu- dents with autism and other ASDs (Williams, Johnson, & Sukhodolsky, 2005). Rapid growth in the number of students with ASDs has compelled many school systems to de- velop policies, programs, and other supports to foster the academic and social growth of this population (Henderson, 2011). However, our understanding of states’ responses to rising prevalence, especially the incidence of school- based identification and educational outcomes of identified students, is quite limited. Prevalence of ASDs Prevalence refers to the number of cases of a condition in a given time period. Early large-scale studies of clinical and community samples estimated ASD prevalence from 1 in 330 children (Fombonne, 2003) to 1 in 90 (Kogan et al., 2009), with an accepted average of approximately 1 in 167 (Worley, Matson, Sipes, & Kozlowski, 2011; see Matson & Kozlowski, 2011, for a review of autism prev- alence research). The most current estimate was | in 88 children (Centers for Disease Control and Prevention [CDC], 2012). Gender differences are common, with males estimated to be as much as five times more likely to be identified with ASD than females (Centers for Disease Control and Prevention, 2012). The CDC estimates, based on data collected in 14 states, suggested that prevalence also varies by race/ethnicity (Centers for Disease Control and Prevention, 2010). Presently, however, nationally representative estimates are lacking (Office of Autism Research Coordination, 2010) and the causes of changes in prevalence are heavily debated. Some attributed the spike to improved awareness among clinicians and the general public, others to the emergence of and changes in diagnostic criteria and mea- sures (Matson & Kozlowski, 2011; Posserud, Lundervold, Lie, & Gillberg, 2010), and still others to changing environmental risks (Gra- fodatskaya, Chung, Szatmari, & Weksberg, 2010). Racial Disparities in ASD Prevalence As Dyches, Wilder, Sudweeks, Obiakor, and Algozzine (2004) noted, much of the early ASD research has either ignored or minimized the issue of race. More recently, however, researchers have begun to consider racial/eth- nic variations in ASD diagnoses. Many of the 14 participating surveillance sites in the ongoing CDC prevalence study demonstrated substantial disparities in prevalence between White and Black children, and between White 299 School Psychology Review, 2013, Volume 42, No. 3 and Hispanic children (Durkin et al., 2010). Mandell and colleagues (2009) utilized data from a subset of CDC study participants and found that (a) only 58% of all children iden- tified with ASDs by the researchers using teria based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) had documented diagnoses in their medical or school records, and (b) minority children were less likely to have documented diagnoses than their White peers. The authors suggested that significant racial disparities in ASD diagnosis may be from systemic or structural factors that contribute to differential treatment in health care and education. Rosenberg, Daniels, Law, Law, and Kaufmann (2009) examined geographic and inician characteristics related to differences in parent-reported autism diagnoses and found that patterns of identification were related to race, region, urbanicity, and type of evaluator (ie., psychiatrist, psychologist, or school- based team), Most children were initially iden- tified by a pediatrician, clinical psychologist, or neurologist, and then later identified for services by school teams at approximately age 6. Although children in rural and urban areas were equally likely to be identified, those in suburban areas or micropolitans were less likely to be initially diagnosed with ASD. There were also significant differences in identification patterns across regions, leading the authors to conclude that states’ educational and legislative contexts may contribute to diagnosis. Autism in Schools Autism became a distinct category of special education eligibility in the 1991 amendments to the Individuals with Disabili- ties Education Act (IDEA; 2012), which also mandated reporting on identification and placement of students with autism beginning in 1993 (Laidler, 2005). In the 10 years fol- lowing the inclusion of autism in IDEA, iden- tification more than quintupled (Laidler, 2005). Under federal law, students with ASD may receive specialized instruction and other 300 educational services and supports when they demonstrate special education eligibility and needs consistent with the federal definition of autism (34 C.F.R. § 300 et seq., 2012; see Table 1). This definition of autism provides the basis for school-based identification of au- tism, and is vague enough that it may allow for the inclusion of students with other ASDs (Shriver, Allen, & Matthews, 1999). Notably, this definition is distinct from the criteria used for clinical diagnoses for autism, Asperger's disorder, Rett syndrome, and other ASDs via the DSM-IV-TR criteria. In particular, a DSM-IV-TR diagnosis requires the presence of the deficits in communication, socialization, and behavior whereas IDEA only requires communication and social deficits with the presence of restricted or stereotyped behaviors noted to be “often associated” with the disor- der (34 C.F.R. § 300fc] [1)). IDEA permits states to modify the fed- eral definition (for examples, see Table 1), which may have implications for identification practices and resultant incidence rates. Mac- Farlane and Kanaya (2009) documented sub- stantial variability in states’ autism criteria and found higher prevalence of school-identified autism, based on mean prevalence for groups of states, where the special education criteria aligned with the DSM-IV-TR definition of autism or included ASDs in the language of the state criteria. States that required autism diagnosis by medical professionals (n = 2) had the highest prevalence, followed by states (n = 20) that included ASDs in their autism criteria, and states (n = 17) that included DSM criteria (these categories were not mu- tually exclusive). Variability in definitions of autism is concerning given the overall low prevalence of school-based identification relative to CDC estimates. Just 0.3% of the school-aged (i.e. ages 6-21) population is classified as autistic, up from 0.07% in 1997 (Office of Special Education Programs, 2011), but still less than a third of what is expected based on CDC estimates (Centers for Disease Control and Prevention, 2012). However, clinical (DSM- IV-TR) diagnoses and special education eligi- bility are not the same because IDEA requires ‘School-Based Autism Identification Table 1 Variations in Autism Criteria: DSM-IV-TR, IDEA, and Examples of State Statutes General Autism Definitions/Criteria Example State Definitions Individuals with Disabilities Education Act Arizona: “{A] developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.” (Id at § 300.8[c] ap DSM-IV-TR A. Six or more items from (1), (2), and (3), wit least two from (1), and one each from (2) and (3): at 1. qualitative impairment in social interaction, as manifested by at least two of the following: a, marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction failure to develop peer relationships appropriate to developmental level c. a lack of spontaneous seeking to share enjoyment, interests, or achievements with ‘other people (e-g., by a lack of showing, bringing, or pointing out objects of interest) 4. lack of social or emotional reciprocity qualitative impairments in communication as manifested by at least one of the following: a, delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) b. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others ¢. stereotyped and repetitive use of language or idiosyncratic language d. lack of varied spontaneous make-believe play or social imitative play appropriate to developmental level b, lent before age three, that adversely affects a child’s educational performance. Other characteristics often associated with autism “Autism means a developmental disability that significantly affects verbal and nonverbal ‘communication and social interaction and that adversely affects educational performance. Characteristics include irregularities and impairments in communication, engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines and unusual responses to sensory experiences. Autism does not include children with characteristics of emotional disability.” (ARS 15-761) Idaho: “Autism is a developmental disability, ‘generally evident before are 3, significantly affecting verbal and nonverbal communication and social interaction, and adversely affecting educational performance. A student who manifests the characteristics of autism after age 3 could be diagnosed as having autism. Other characteristics often associated with autism include, but are not limited to, engagement in repetitive ac and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. Characteristics vary from mild to severe as well as in the number of symptoms present. Diagnoses may include, but are not limited to, the following autism spectrum disorders: Childhood Disintegrative Disorder, Autistic Disorder, Asperger's Syndrome, or Pervasive Developmental Disorder. Not Otherwise Specified.” (PDD:NOS) West Virginia: 1. Student must (1) meet criteria identical to DSMAIV, and “(2) The student is diagnosed as having autism by a psychiatrist, physician, lincensed psychologist or school psychologist. (3) ‘The student’s condition adversely affects educational performance. (4) The student (Table 1 continues) 301 ‘School Psychology Review, 2013, Volume 42, No. 3 Table 1 Continued General Autism Definitions/Criteria Example State Definitions 3. restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: ‘a, encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus . apparently inflexible adherence to specific, nonfunctional routines or rituals stereotyped and repetitive motor manners (e.g., hand or finger flapping or twisting, or complex whole-body movements) needs special education. (5) The student’ seducational performance is not adversely affected primarily because the student has an emotional/behavioral disorder as defined in this chapter.” (West Virginia Policy 2419) d. persistent preoccupation with parts of objects the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or iaginative play. The disturbance is not better accounted for by Reit’s Disorder or Childhood Disintegrative Disorder. Delays or abnormal functioning in at least one of Note. DSM-IV-TR = Diagnostic Statistical Manual, 4th ed., Improvement Act. text rev.); IDEA = Individuals with Disabilities Education that the disorder “adversely affects a child's educational performance” in order to qualify for special education (34 CER. § 300.8{c] [1)). It is possible that the disorder does not substantively affect the behavior or school per- formance of many children and youth with autism or other ASDs. Moreover, most prev- alence studies have relied on community or clinical samples, so the prevalence of autism in schools (i.e., children identified for special education services based on ASDs) remains unclear, particularly across racial groups. Disproportionality in Special Education Within the special education literature, there has been considerable attention to racial disparities in identification and treatment of disabilities predating even the codification of special education (e.g., Dunn, 1968; for re- views of the literature, see Donovan & Cross, 2002; Waitoller, Artiles, & Cheney, 2010), but 302 attention has focused almost exclusively on learning, intellectual, and emotional disabili- ties. Data featured in the Office of Special Education Programs annual reports and the seminal report from the National Research Council (Donovan & Cross, 2002) indicated racial disparities in autism identification that exceeded those of the more often studied dis- abilities. However, the patterns of racial dis- parity were largely overlooked in studies of special education identification disparities (Sullivan & Artiles, 2011), which may have broad implications given the influence of this larger body of research on national policy and professional practice. Recent national aggregates indicate that risk of school-based identification of autism is highest among Asian/Pacific Islanders (Office of Special Education Programs, 2011), which conflicts with CDC estimates indicating the disorder is most common among White and School-Based Autism Identification Black children (Centers for Disease Control and Prevention, 2012). Travers, Tincani, and Krezmien (in press) examined national aggre- gates of Office of Special Education Programs state-level data from 1998 to 2006 and found that overall risk of autism has quadrupled since 1998, but all minority groups, and par- ticularly Hispanic and American Indian/Alas- kan Native students, were increasingly less likely to be identified with autism compared to White students. However, examination of na- tional aggregates alone provides only the most rudimentary analysis, as it can mask substan- tial variations at more fine-grained levels of analysis (Sullivan, 2011) and does not allow for consideration of factors that may be related to disproportionality. Further, interstate vari- ability in school-based autism identification has been identified as a public health concern because of the centrality of school-based iden- tification to prevalence studies, and by exten- sion, public policy (MacFarlane & Kanaya, 2009), and variability might expose potential gaps in services to children with autism. Rapidly changing prevalence estimates and emerging evidence of racial disparities autism identification necessitate more nuanced examinations of prevalence, racial dispropor- tionality, and potential correlates of dispari- ties. The Centers for Disease Control and Pre- vention (2009b) surveillance study suggested that although 80% of all children with autism who were identified by researchers received special education services under some disabil- ity category, there was wide variability across states, with some states identifying as few as one-third for special education and others identifying over 95%. Few studies have exam- ined the factors related to variations in preva- lence of school-based autism identification and there has been even less attention to correlates of race-based differences in identification. States’ prevalence of school-based iden- tification of autism was predicted by per pupil spending and the number of school health clinics in the state (Mandell & Palmer, 2005). Moreover, the increasing rate of students with autism in Canada was partially accounted for by changes to existing special education clas- sifications, particularly for intellectual or health impairments (Coo, Oullette-Kuntz, Lloyd, Kasmara, Holden, & Lewis, 2008). which was consistent with earlier research in the United States (Brock, 2006; Shattuck, 2006). Morrier and Hess (2012) examined whether geographic region and use of the de- velopmental delay category was related to rel- ative risk of autism among racial groups, and found group mean differences between states in different geographic regions, but not based on use of developmental delay. More research is needed to understand the extent to which policy and other state characteristics contribute to differences in prevalence and group risk. Current Study The purpose of this study was to exam- ine prevalence and relative risk of school- based autism identification by race (ie., mi- nority groups” prevalence of autism compared to White students” prevalence), and the extent to which prevalence and disproportionality were predicted by state characteristics. This study was grounded in Kilbourne, Switzer, Hyman, Crowley-Matoka, and Fine (2006) conceptual model for health disparities re- search in which three components were delin- eated: (1) definition and detection of disparities, (2) identification of individual, practitioner, and systemic determinants, and (3) develop- ment and evaluation of interventions and pol- icies to reduce disparities. The present study contributed to Phases | and 2 of this model by examining racial differences in autism preva- lence and treatment. As such, the following research questions guided the analyses: 1. To what extent does prevalence vary across states’? 2. To what extent does relative risk of au- tism diagnosis vary among the four race/ ethnicity minority groups, compared to White students, at the national and state levels? 3. How are prevalence and relative risk predicted by state population demo- graphics and special education policy? Scholars increasingly recognize that lo- cal factors influence autism prevalence (Leon- 303 School Psychology Review, 2013, Volume 42, No. 3 ard et al., 2010). Although state-level data do not allow for analysis of diagnostic practices or decisions, they may provide insight into systemic patterns of identification. This study was designed to examine the degree to which autism prevalence and racial disparities were predicted by characteristics of the states’ de- mographics (i.e., proportion of minority en- rollment), special education programming (ie., percentage of students with any disabil- ity; intellectual disability [ID], specific learn- ing disability [SLD], and speech-language im- pairment [SLI}); and change in ID and autism identification rates), and policy (i... inclusion of DSM-IV criteria and ASDs in states’ autism definitions). Given the exploratory nature of this study, specific directional hypotheses were not specified. Variables under consideration included the diversity of states’ school enrollment as a predictor as this variable because the Centers for Disease Control and Prevention (2012) recently suggested that local demographic dif- ferences may influence ASD prevalence. Mi- nority enrollment in schools has been shown to predict racial disparities in the high-inci- dence disability categories (e.g., Coutinho, Oswald, & Best, 2002; Finn, 1982; Parrish, 2002). Thus, here, it was considered whether diversity in states" student population was re- lated to school-based autism prevalence and racial disparities in prevalence. Characteristics of states’ special educa- tion programs were included in the anal because they predict racial disparities in the identification of other disabilities and because they are posited to be related to variations in school-based identification of autism, This al- lowed for exploration of whether trends iden- tified in the most recent Centers for Disease Control and Prevention (2012) surveillance re- port predicted prevalence and/or racial dispar- ities (e.g., SLD, ID, and SLI rates). The pro- portion of the states’ enrollment identified for special education was included to determine whether overall rates of special education dis- abilities predicted autism prevalence, as there is some evidence to suggest that minority dis- proportionality is related to the broader pro- portion of at-risk or disabled students (e.g., 304 Oswald, Coutinho, Best, & Singh, 1999). Prevalence rates for SLD, SLI, and ID were included as predictors because these are the three categories, following autism, in which individuals with ASD are most likely to be served (Centers for Disease Control and Pre- vention, 2012) and are the disabilities most subject to inappropriate identification as au- tism (Leonard et al., 2010). Furthermore, Shat- tuck (2006) presented evidence to suggest that increased prevalence in autism is related to states’ ID and SLD rates. In addition, because of concern that in- creased autism prevalence is from systematic shifts in students’ disability classifications from ID to autism, the predictive utility of 3-year change in states’ rates of ID and autism was included in the analysis. There is some evidence that a large proportion the growth in autism prevalence is accounted for by system- atic diagnostic substitution (Coo et al., 2008), but findings in this area are mixed (e.g., New- schaffer, Falb, & Gurney, 2005) and recent U.S.-based and state-level analyses are lacking. Finally, in order to extend the descrip- tive analyses of MacFarlane and Kayana (2009), characteristics of states’ autism crite- ria were also included as predictors of both prevalence and racial disparities. These au- thors coded states’ definitions of autism along four dimensions indicating if they included (a) only the IDEA definition of autism, (b) all or part of the DSM-IV-TR criteria for autism (i.e., items described in the DSM-IV-TR cri- teria presented in Table 1), (c) explicit men- tion of other ASDs, and (d) a requirement that pediatricians or other clinicians to be on the evaluation team. The inclusion of DSM- IV-TR and ASD in states’ definition was in- corporated in the present study because MacFarlane and Kayana’s (2009) descriptive analysis indicated differences in mean preva- lence between groups of states for each of the codes. Method Sample State-level data were obtained from the Data Accountability Center (www.idead- ‘School-Based Autism Identification ata.org), which is a federally funded technical assistance center that collects data from states, under the requirements of IDEA. Specifically, data were drawn from two publically available Data Accountability Center sources: (1) the 2008 IDEA $618 child count data submitted in February 2009 by state education agencies, and (2) 2008 census estimates of states’ school-age population. At the time of this analysis, the data for 2008 were the most re- cent complete data available. The sample in- cluded 46 states because Alaska, Massachu- setts, New Jersey, Vermont, and the District of Columbia did not report complete data, The total sample included a national population of 65.9 million children ages 6-21, of which 60.4% were White, 19.4% were His- panic, 15% were Black, 4.3% were Asian/ Pacific Islanders, and 0.95% were American Indian or Alaskan Natives. Variables The 2008 raw data from Data Account- ability Center included (a) number of students ages 6-21; (b) number of students ages 6-21 by race; (c) number of students ages 6-21 identified with autism, SLI, SLD, and ID; and (d) number of students ages 6~21 with autism by race in order to create the following out- comes: statewide prevalence of autism, prev- alence of autism for each racial group, and relative risk of autism for each minority group compared to White students. Then, the follow- ing predictor variables were created: propor- tion of students from racial minority groups in the school-aged population, the proportion of students receiving special education for any disability, and the prevalence of school-iden- tified ID, SLD, and SLI. In addition, the pro- portions of school-aged students identified with autism or ID in 2005 were estimated in order to calculate the 3-year change in preva- lence for ID and autism from 2005 to 2008 by subtracting the 2005 prevalence from the 2008 prevalence and dividing by the 2005 preva- lence, thus yielding a value indicating the per- centage increase or decrease in autism and ID. Descriptive statistics for these predictors are provided in Table 2. Finally, MacFarlane and Table 2 Descriptive Characteristics of Predictors Predictor Mean SD Range % Enrollment 31.28 16.61 5.75-73.38 minority % Receiving special 8.91 1.25 6.85-11.66 education services ID prevalence 0.75 O41 0.29-2.18 SLD prevalence 3.68 0.81 1.54-5.65 SLI prevalence 172 0.54 18 Three-year change 0.11 0.09 —0.31-0.16 in ID Three-year change 0.52—:0.19 —0.42-0.11 in autism Note, 1D = intellectual disabilities; SLD = specific learn- ing disabilities; SLI = speech-language impairment, Kanaya’s (2009) categorization of states’ 2008 special education statutes were used to create two dichotomous variables reflecting whether the states’ autism criteria incorporated DSM- IV's autism criteria (n = 16) or ASD (n = 18). Analysis Prevalence and relative risk. Preva- lence was estimated using the following for- mula (Centers for Disease Control and Preven- tion, 2009a): (1) Prevalence= Number of students ages 6-21 identified with autism in 2008 Total population of children ages 6-21 in 2008 x 100 Prevalence was estimated for the total school-aged population of the nation and each state and for each race/ethnicity category (i.e., White, Black, Hispanic, American Indian/ Alaskan Native, and Asian/Pacific Islander). The prevalence estimates were used to ascertain relative risk for the four minority racial groups using the relative risk ratio, which is an epidemiologic statistic and mea- 305 School Psychology Review, 2013, Volume 42, No. 3 sure of effect size commonly used in health research to compare binary outcomes between groups (e.g., autistic/not autistic; Mason, Scott, Chapman, & Tu, 2000) and a common indicator of disproportionality. Relative risk is determined by computing a ratio of the prev- alence for a given minority group relative to prevalence for a referent group (c.g., Black students’ prevalence divided by White stu- dents’ prevalence). White students were se- lected as the referent group following the ra- tionale of Artiles, Rueda, Salazar, and Hig- areda (200! (a) White students have been traditionally used as a comparison group in equity analy- ses because they are the dominant group in society who have not had systematic prob- ems with access and opportunity issues, (b) White students have been used historically as a contrast group in this literature that facili- tates trend analyses, and (c) White students can be used as a stable contrast group be- cause various cultural and linguistic groups ‘are compared to the same group. (p. 289) A relative risk ratio of 1 indicates equal prevalence between the two groups. A positive value indicates that the minority group is more likely than the referent group to be identified with autism (e.g., a value of 1.5 indicates that the minority group is 50% more likely to be identified), whereas a value less than | indi- cates that the minority group is less likely to be identified (e.g., 0.85 indicate that the mi- nority group is 15% less likely to be identified than Whites). In addition, chi-squared analysis were applied to identify statistically significant differences in minority prevalence relative to White students (Laidler, 2005) using MedCale (Medcalc Software Version 12.2.1.0, 1993). Predictors of prevalence and risk. Five linear regression models were estimated to determine if prevalence and relative risk were functions of the state characteristics of interest. All variables were standardized (z scores) to meet the assumptions of linear re- gression. Because of the exploratory nature of this analysis, all variables were simultane- ously entered in the model. All variance infla- tion factors were within acceptable limits, in- dicating collinearity was not a problem (Co- 306 hen, Cohen, West, & Aiken, 2003). The backward elimination procedure in SPSS was used in the regression analysis such that all predictors were included in the initial model, which was sequentially refitted eliminating the weakest variables (p .10) until only the use- ful predictors remained in the final model. Results for the final models, including ad- justed R squared (AR’) are reported. (Note: Results for all of the preliminary models can be obtained from the author.) Results Prevalence Across States Table 3 describes the prevalence of au- tism according to school-based identification for the total sample as well as descriptive statistics for state-level prevalence and relative risk by minority group. In 2008, schools across 46 states identified 272,311 students with autism under IDEA, resulting in a na- tional prevalence of 0.44, which means schools identified 1 in 228 students with au- tism, There was considerable variation among states, with prevalence ranging from 0.11 to 0,99. The distribution was positively skewed as two-thirds of states had prevalence below 0.44, Relative Risk of Autism Diagnosis Among the Four Race/Ethnicity Groups at the National and State Levels At the national level, autism prevalence was significantly higher for White students than Black students (x? = 794.77, df = 1, 001), Hispanic students (x? = 7736.55, df = 1, p <. 001), and American Indian/ Alaskan Native students (x? = 175.72, df = 1, p <. 001). Conversely, Asian/Pacific Islander students were significantly more likely than White students to be identified with autism by schools (x? = 499.79, df = 1, p < .001). Differential prevalence was most pronounced for Hispanic students, who were nearly 40% less likely to be identified with autism nation- ally than White students (relative risk ra- tio = 0.61). School-Based Autism Identification Table 3 Prevalence and Relative Risk of Autism Identification at the National and State Levels Prevalence/ American Indian/ Asian/Pacific Relative Risk All Races White Black -—Hispanic.-—-Native Alaskan Islander National Total N 62,373,801 37,518,251 9,411,508 12,266,044 590,676 2,587,322 Autism 272,311 180,623 38,466 2 2,099 14,984 Prevalence 0.44 0.48 o0.41* 0.29* 0.36" 0.58" Relative risk = — — 085 061 0.74 1.20 State n n=46 n=45 1 =43 n=40 M prevalence 0.42 0.45 0.43 0.24 0.42 SD 0.17 0.18, O18 O11 0.27 Minimum 0.11 010020 0 Maximum 0.99 1.02 1.09 0.59 1.39 M relative risk od - 0.99 0.55 0.87 SD _ - 0.36 0.18 0.38, Minimum — _ 0 0 0 Maximum = — — 2n 12 1.66 NRRR<08 — - 9 44 21 NRRR>I20 — = 5 1 8 21 Note, Prevalence is determined by the Centers for Disease Control and Prevention formula described in the method. RRR = relative tisk ratio (ie., minoriry group prevalence/White prevalence). *indicates that comparison of prevalence to that of White students’ was significant (p < .001). The number of states for which RRR could be calculated varied by racial group because, than 5 students were ider federal reporting requirements, states suppress autism enrollment for groups where fewer fied to prevent disclosure of identifying student information. Figure 1 displays states’ relative risk ratios. At the state level, racial disparities were common, particularly for Hispanic, American Indian/Alaskan Native, and Asian/Pacific Islander students. Hispanic students were less likely to be identified with autism than White students in 44 of 46 states and were at least half as likely as White students to be identified with autism in half of the states in the country. American Indian/Alaskan Native students were also generally less likely to be identified with autism across states. In contrast Asian/Pa- cific Islander students were more like to be identified with autism than White students in most states, and, were on average, 20% more likely to be identified with autism for special education. Proportional identifica- tion was most common for Black students. Prevalence Rates and Relative Risk Predicted by State Population Demographics and Special Education Policy ‘The model for overall autism prevalence was significant, AR? = 42, F(5, 40) = 7.49, p <.01, with five predictors: special education enrollment, B = .89, 1(4.78), p < .001; ID prevalence, 8 = —47, (—3.64), p < .001; SLD prevalence, B = -.63, (—4.14), p < 001; SLI prevalence, B = —.32, 1(—2.08), p< .05; and ASD in the state autism defini- tion, B = 37, 13.19), p < .001. Thus, incor- poration of ASD in the state's policy and higher overall likelihood of disability in the school-age population predicted higher preva- lence of ASD. There was an inverse relation ship between autism prevalence and the prev- alence of ID, SLD, and SLI. 307 ‘School Psychology Review, 2013, Volume 42, No. 3 Oe Aeen nin BAPE “Rick “OH Figure 1. Racial minority groups’ relative risk of school-based autism identi- fication varied substantially by state in 2008-2009. The relative risk ratio is a ratio of the prevalence for the minority group and White students. In states where a groups’ marker is absent (e.g., American Indian and Asian/Pacific Islander students in South Carolina), this indicates there was insufficient subgroup population to calculate relative risk. In most states (n = 33), Asian students were more likely to be identified with autism than Whites as indicated by relative risk ratios above 1 (indicated by the dotted horizontal line). His- panics students tended to be less likely to be identified as states’ relative risk ratios were commonly less than 1 (n = 41). Although the highest relative risk was found among Black students in lowa and North Dakota, Black students were less likely to be identified than White students in 30 states. PI = Pacific Islander. The final model for Asian/Pacific Is- landers’ relative risk was significant, AR® = 21, F(4, 41) = 4.03, p < 01, with three predictors: special education enrollment, = — 45, (3.04), p < .001; ID prevalence, B = 32, 1 (2.14), p < .05; and inclusion of ASD criteria, 8 = —.30, (2.18), p < .05. Thus, Asian American students were less likely to demonstrate higher autism prevalence than White students in states with larger special education enrollments or where ASD was in- cluded in the autism definition. Conversely, ID 308 prevalence was a positive predictor of Asian American’s relative risk. The model for American Indians’ rela- tive risk was significant, AR? = 24, F 3, 42) = 3.91, p < .01, with three predictors: special education enrollment, B = —.35, 12.15), p < .05; ID prevalence, B 3, 1(—2.26), p < .05; and SLI prevalence, B = ~.50, (—3.26), p < .01. Relative risk of au- tism identification for American Indians was inversely related to overall disability preva- lence as well as the prevalence of ID and SLI. School-Based Autism Identification In other words, American Indians were in- creasingly likely to be identified with autism relative to White students when ID and SLI identification was lower and smaller propor- tions of students overall were identified for special education. Only the percentage change in autism prevalence was a significant predictor, B —.47, (—3.51), p < 001, in the final model for Hispanic students’ relative risk, AR? = .20, FUL, 44) = 12.31. For Black students, only minority enrollment, B = (-2.14), p < .05, and percentage change in autism prevalence, B = —.49, (3.95), p < .001, were significant in the final model, AR? 31, F(2, 43) = 11.51, p < 001. Thus, Hispanic and Blacks’ risk was greatest, rela- tive to Whites, in states where growth in au- tism prevalence was lowest. The relative risk of Black students was higher in states with a smaller proportion of minority students and states where there had been little overall change in autism prevalence. Discussion This study adds to the small but growing body of literature demonstrating the variability and racial disparities in school-based auti prevalence by describing state-level variation in prevalence and results of an exploratory regression analysis of the relations of preva- ence and minority relative risk to state char- acteristics. The present analysis provides evi- dence of widespread racial disproportionality and state-level variability in the identification of autism in schools, and highlights the need for greater attention to this issue. Prevalence of Autism in Special Education Nationwide, public schools identified 1 in 228 students as having autism in 2008. Across 46 states, identification rates ranged from | in 933 to 1 in 101 children, indicating that states served far fewer students with spe- cial needs under the autism eligibility category than the overall ASD prevalence of 1 in 88 indicated in the 14-site CDC study for the same time period (Centers for Disease Control and Prevention, 2012). The current estimate provides a different picture of school-based autism identification than the basic estimates of prevalence obtained in studies that only describe overall national prevalence (c.g., Travers et al., in press) because the majority of states had prevalence rates more than 10 points different from the national estimate. Centers for Disease Control and Prevention (2012) estimates suggested that higher rates of autism would be found here since CDC sites including special education records in their prevalence estimation reported higher overall prevalence than those that did not. However, the Centers for Disease Control and Preven- tion (2012) study may have also inadvertently captured states with above average special ed- ucation autism prevalence. These results also underscore the importance of considering prevalence at multiple levels of analysis (e, school, district, state, nation) because variabi ity is to be expected. The current results suggest a need to examine why wide variations in autism prev- alence exist across states and school systems. Variability in identification may be partially attributable to the lack of special education needs among some students with milder forms of ASD (Brock, Jimerson, & Hansen, 2006), including those who received effective early intervention. Nonetheless, given the continued frequent co-occurrence of intellectual impair- ments and severe behavior difficulties among children with autism, the discrepancy between clinical and school identification has raised concern that students with autism are underi- dentified and underserved in schools (Brock et al., 2006; Safran, 2008). The Centers for Disease Control and Prevention (2012) posited that the increased prevalence noted in its studies was likely from changes in how the disorder was evaluated (eg., improvements in screening); perhaps the apparent underidentification of students in schools was from similar causes. That is, lower prevalence of school-based autism diag- noses may be attributable to insufficient prac- titioner preparation for identifying this disor- der or inadequate diagnostic tools. The gold standard for assessment of autism is a multi- 309 School Psychology Review, 2013, Volume 42, No. 3 method, multisource assessment conducted by a multidisciplinary team utilizing instru- ments with high specificity and sensitivity (Woolfenden, Sarkozy, Ridley, & Williams, 2012). Although this standard is consistent with the spirit of IDEA, research has not suf- ficiently examined the diagnostic practices uti- lized in school-based identification of autism. However, there is some evidence that the prac tices applied by school psychologist deviate substantially from best practice recommenda tions (e.g., Allen, Robins, & Decker, 2008) Research in community-based health care set- tings found little agreement among clinicians regarding children’s diagnoses and that many clinicians failed to use appropriate procedures (Williams, Atkins, & Soles, 2009). Forthcoming changes to the clinical def- initions of ASDs in the fifth edition of the DSM may also have implications for the prev- alence of school-identified autism. The pro- posed definition subsumes the previously dis- tinct autistic disorder, Asperger's, childhood disintegrative disorder, and pervasive devel- ‘opmental disorder into a single disorder and merges social and communication deficits into a single domain (American Psychiatric Asso- ciation, 2012). The proposed changes have sparked concern that many individuals with ASD, particularly those with average or better cognitive functioning, will no longer meet dis- order criteria (McPartland, Reichow, & Volk- mar, 2012). Whether these changes will influ- ence federal or state policy and local identifi- cation practices, and, by extension, rates of autism identification in schools, is also a worthwhile topic for future studies. Racial Disparities in School-Based Autism Identification The results of this study showed that there were significant differences in the iden- tification of autism across racial groups. Rel- ative to White students, Asian students were more likely to receive special education ser- vices for autism while Hispanic students were the less likely in most states, Although the apparent underidentification of Hispanic stu- dents with autism has been shown elsewhere 310 Centers for Disease Control and Preven- tion, 2012), the widespread relative low prev- alence among American Indian/Alaskan Na- tive students and high prevalence of Asian/ Pacific Islander students relative to White students was somewhat unique and is the op- posite of these groups’ typical patterns in other categories of special education eligibility (Donovan & Cross, 2002). Three dynamics may underpin these findings: (a) White and/or Asian/Pacific Islander students may systemat- ically be inappropriately identified with au- tism, (b) other minority students may be s; tematically underidentified with the disability, or (c) true group differences in special educa- tion needs may exist. It is not possible to determine the extent to which observed differ- ences reflect disparities in identification prac- tices versus true group differences in preva- lence. In general, these findings underscore the need to study this issue further to inform train- ing and intervention efforts. Although this study and others docu- mented racial disparities in autism prevalence, these identified disparities only suggest that something may be amiss in the diagnostic process. It is the validity of the practices sur- rounding referral, diagnosis, and intervention that determines whether such patterns are truly problematic or simply indicative of differen- tial risk of the disorder (Rueda & Windmuel- ler, 2006). At this time, there is not enough research to know which is the case, but several studies suggests points of potential bias and inequity in the referral process. These will need to be explored further to determine the nature of these racial disparities. Although education scholars have re- garded autism as an objective medical diagno- sis, physicians have acknowledged “the diag- nosis of autism is completely subjective” (Laidler, 2005, p. ¢123). Indeed, many con- sider “clinical judgment” to be the gold stan- dard for autism diagnosis (Wolfenden et al., 2012), yet there is much research to suggest that clinical judgment is highly flawed (Wat- kins, 2008). These findings challenge the no- tion that autism is an objective diagnosis free from the subjectivity noted in the high-inci- dence special educational categories (Sullivan School-Based Autism Identification & Artiles, 2011). Thus, research examining the factors influencing school-based identifi- cation is necessary so that we can ensure that students receive appropriate diagnosis, inter- vention, and support. For example, future re- searchers could examine how education pro- fessionals conceptualize and diagnose autism, and potential biases in the recognition of those features in students with varying sociodemo- graphic characteristics (Brock et al., 2006). There is a broader concer that clini- cians may not be able to differentiate ASD from other developmental delays (Worley et al., 2011) as previous research indicated many educators and school-based practitioners felt underprepared to serve students with autism (Simpson, de Boer-Ott, & Smith-Myles, 2003). It is feasible that the low-prevalence among some minority groups may be at least partially explained by insufficient capacity of educational professionals and systems to iden- tify and support the needs of children with autism, but particularly those who demon- strate certain cultural and linguistic differ- ences. Studies of the school-based identifica- tion process are especially important given that other studies have not found the substan- tial racial disparities found here (e.g., Centers for Disease Control and Prevention, 20092), and numerous studies suggest that Black, American Indian, and Hispanic students are systematically overidentified with other dis- abilities in elementary and secondary school (Waitoller et al., 2010). Conversely, minority children are generally less likely to receive early intervention services during early child- hood than White children (Komzelman, Sulli- van, & Caterino, 2010), which may contribute to delayed or inappropriate identification of students with autism, Brock and colleagues (2006) suggested that lower identification rates for minority children may also reflect practitioners’ willingness to classify Black children as intellectually disabled relative to their hesitance to do so with White students. Taken together, these studies emphasize that future research should examine how student sociodemographic characteristics affect case conceptualization and educational decision making from early childhood onward. Research regarding student sociodemo- graphic characteristics and educational deci- sions should also be informed by research conducted in clinical settings. For instance, previous research found that clinicians recog- nized autism less readily in Black children, requiring three times more contact to render diagnoses for Black children than White chil- dren (Mandell, Listerud, Levy, & Pinto-Mar- tin, 2002). Given the time constraints placed on school-based identification, a similar dy- namic would likely contribute to inappropriate diagnoses. Researchers have also found that children from higher income households are more likely to be diagnosed with ASD than children from lower SES homes (Durkin et al., 2010), and that SES was a stronger predictor of receipt of state services than symptom se- verity (Fountain, King, & Bearman, 2011). Still others have demonstrated that ASD may be mistaken for attention deficiv/hyperactivity disorder or oppositional defiant disorder in some minority groups (Mandell et al., 2009). Studies also show parents hold a variety of beliefs about autism etiology and treatment that may influence students’ services (Dardennes, Al Anbar, Prado-Netto, Kaye, Contejean, & Al Anbar, 2011). In general, these findings point to the need for research examining the problem-solving process, team members’ conceptualizations of student diffi- culties, and reliability of diagnosis for identi- fication of autism in schools. State Characteristics Associated With Patterns of Identification The current data highlighted the poten- tial influence of state special education criteria for autism and broader identification trends. Although IDEA criteria were broad, whether states explicitly included ASD in their autism definition predicted overall prevalence and rel- ative risk among Asian-American students, suggesting the language of state policy sub- stantially affects practices. Counter to Mac- Farlane and Kanaya’s (2009) descriptive find- ings, prevalence rates were not predicted by the inclusion of DSM-IV-TR criteria in the state’s special education criteria for autism 311 ‘School Psychology Review, 2013, Volume 42, No. 3 eligibility. Moreover, prevalence of autism identification for special education was not predicted by changes in the prevalence of in- tellectual disabilities, as was noted in previous research (Brock et al., 2006; Jick & Kaye, 2003), but was related to current rates of ID, SLD, and SLI. The relationship between the prevalence of autism and other disabilities again pointed to the need to examine issues related to differential identification in special education. The influence of ID rates in particular may be related to the disorders’ common con- founding and comorbidity with autism. It was estimated that approximately 40% of children with autism have IDs (Centers for Control and Prevention, 2012), but it is un- clear how educational practitioners differenti- ate autism with cognitive impairments from IDs alone as both groups demonstrate lan- guage and social difficulties. Autism preva- lence was also inversely related to the preva- lence of SLD and SLI, two disabilities com- monly identified and misdiagnosed in children with autism (Centers for Disease Control and Prevention, 2012; Leonard et al., 2010). When considered alongside Centers for Disease Con- trol and Prevention (2012) findings that large proportions of students with ASD are not iden- tified with autism by their schools, there are a few potential explanations for these findings: multidisciplinary teams may identify students with ID, SLI, or SLD when these appear to better reflect the source of students’ academic difficulties, or teams may systematically tend toward the identification of the high-incidence disabilities because they fail to recognize au- tism or have some other bias in diagnostic practices. The latter possibility points to a need to train multidisciplinary team members to screen for autism and make differential diagnoses. It is noteworthy that the variables re- lated to overall prevalence did not consistently predict racial disproportionality. The lack of relationship between prevalence in racial dis- proportionality suggests that the factors influ- encing racial disparities, particularly among Hispanic and Black students, are different from those shaping general prevalence, which 312 has also been found in studies of racial dis- proportionality in other disability categories (Sullivan & Artiles, 2011; Skiba, Poloni- Staudinger, Simmons, Feggins-Azziz, & Chung, 2005), However, the patterns here were quite different from those observed in the disability categories typically studied (ie., Black and American Indian students often demonstrate the highest risk of learning, emo- tional, and intellectual disabilities and White and Asian American students are at lower risk), which implied that the relations under pinning the observed disproportionality in au- tism were different than other disability cate- gories. It was interesting that relative risk for both Hispanic and Black students was in- versely related to overall growth in autism prevalence, which may suggest that in states with substantial change, much of it was attrib- uted to the identification of White students. More fine-grained analyses are needed to iden- tify the mechanisms behind the systems-level relations seen here. Other state factors to be considered in future research include service coordination and special education funding formulas in particular as autism is one of the most expensive eligibility categories (MacFar- lane & Kanaya, 2009), In sum, we need more research to understand the systemic, interper- sonal, and intraindividual factors that contrib- ute to differential identification and treatment of autism. Limitations Although this study contributes to our understanding of patterns and correlates of prevalence in school-based identification of autism, several limitations are notable. This ‘was a correlational study that relied on aggre- gate secondary data reported by state depart- ments of education, and was thus limited to group-level analyses and the uniform catego- rization of racial groups required in the federal reporting, which, at the time, combined Asian, Native Hawaiian, and other Pacific Islanders into a single category and did not allow indi- viduals to identify as two or more races. This study was also limited to data from 2008, which were the most recent available. Al- School-Based Autism Identification though this allowed for comparison to the current CDC (2012) results, the data may not fully reflect actual trends at the present time. Prior literature has noted the tations of using this type of administrative data (Laidler, 2005; Mandell & Palmer, 2005; Newschaffer et al., 2005; Volkmar, Lord, Bailey, Schultz, & Klin, 2004), especially for estimating gen- eral prevalence (e.g., Laidler, 2005), but that ‘was not the purpose here. The present analysis considered only diagnosed students and did not include students who have all of the req- uisite symptoms but remain undiagnosed, which has been recognized as important in understanding both the prevalence and effect of this disorder (Office of Autism Research Coordination, 2010). This particular dichot- omy may be critical to furthering our under- standing of school-based disproportionality in autism. Despite these limitations, there are notable strengths to this type of analysis. As Shattuck (2006) stated, state-level analyses provide an ecological perspective with impli- cations for systems interventions and greater generalizability than findings from selected school systems. Policy Implications and Conclusions The present results underscore the need to consider geographic and racial differences in autism identification and how these may be related to systemic factors (e.g., educational policies, procedures, and systemic patterns of identification). The critical policy issue here is the capacity of school systems to provide ap- propriate services for students with ASD. Spe- cial education remains a fundamental gateway to specialized services and the racial dispari- ties identified here may reflect broader issues of differential health care access and treatment (Shattuck & Grosse, 2007). Just as racial dis- proportionality in the high-incidence catego- ries is examined by state departments of edu- cation on an annual basis, so should racial disparities in autism identification, as statisti- cally and clinically significant disproportion- ity appears to be widespread. Further, just as IDEA requires targeted state initiatives to pro- mote appropriate identification of students with high-incidence disabilities, states should provide targeted training to general and spe- cial education teachers, as well as related ser- vice providers, to prevent inappropriate or un- deridentification of students with autism. 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