Received: 18 May 2020 Accepted: 10 February 2021

DOI: 10.1002/aur.2492

RESEARCH ARTICLE

Educational classifications of autism spectrum disorder and

intellectual disability among school-aged children in North
Carolina: Associations with race, rurality, and resource availability

Eunsoo Timothy Kim1 | Lauren Franz1,2,3 | Danai Kasambira Fannin4 |

Jill Howard5 | Gary Maslow5,6

1
Duke Global Health Institute, Duke
University, Durham, North Carolina
2
Department of Psychiatry and Behavioral
Sciences, Duke Center for Autism and Brain
Development, Duke University School of
Medicine, Durham, North Carolina
3
Division of Child and Adolescent Psychiatry,
Center for Autism Research in Africa,
University of Cape Town, Cape Town,
South Africa
4
Department of Communication Sciences and
Disorders, College of Health and Sciences,
North Carolina Central University, Durham,
North Carolina
5
Department of Psychiatry and Behavioral
Sciences, Duke University School of Medicine,
Durham, North Carolina
6
Department of Pediatrics, Duke University
School of Medicine, Durham, North Carolina
Correspondence
Eunsoo Timothy Kim, 310 Trent Drive,
Durham, NC. USA.
Email: eunsoo.kim@duke.edu
Funding information
ARC of North Carolina and the state of North
Carolina; Global Mental Health Initiative at the
Duke Global Health Institute; National
Institute of Mental Health, Grant/Award
Numbers: 1R21MH120696, 5K01MH104370;
National Institute on Minority Health and
Health Disparities NCCU Center for
Translational Health Equality Research
(CTHER), Grant/Award Number: P20
MD000175-13
Abstract
Disparities exist in the recognition of autism spectrum disorder (ASD) and intel-
lectual disability (ID) in racial/ethnic minorities in the United States. This study
examined whether rurality, race/ethnicity, and low resource availability are associ-
ated with disparities in primary educational classifications of ASD and ID in
North Carolina (NC). Descriptive maps were created. Multilevel logistic regres-
sion models examined two separate outcomes (mild ID vs. ASD; moderate/severe
ID vs. ASD). For the interaction term included in the model (race/ethnicity and
residence), predicted probabilities were estimated and plotted. The effects of other
covariates were also estimated. Rural counties had fewer students with ASD and
a greater number of students with ID compared to urban counties. The majority
of students with ASD were non-Hispanic Whites, while the majority of students
with ID were non-Hispanic Blacks. Compared to non-Hispanic White students,
non-Hispanic Black students were overrepresented in the ID classification and
underrepresented in the ASD classification across urban and rural areas. Indica-
tors of low resource availability were also associated with higher probabilities of
ID vs. ASD classification. Differences in primary educational classification based
on urban–rural divide, race/ethnicity, and resource availability are important to
understand as they may point to disparities that could have significant policy and
service implications. Because disparities manifest through complex interactions
between environmental, socioeconomic and system-level factors, reduction in
these disparities will require broader approaches that address structural determi-
nants. Future research should utilize disparity frameworks to understand differ-
ences in primary educational classifications of ASD and ID in the context of race/
ethnicity and rurality.
Lay summary
Rural counties in North Carolina had fewer students with ASD and a greater
number of students with ID compared to urban counties. Compared to non-
Hispanic White students, non-Hispanic Black students were over-represented in
the ID educational classification and underrepresented in the ASD classification.
Differences in classification of ASD and ID based on urban–rural divide, race/
ethnicity, and resource availability may point to disparities that could have signifi-
cant policy and service implications.

KEYWORDS
autism spectrum disorder, health disparities, intellectual disability, race, rurality

Eunsoo Timothy Kim and Lauren Franz should be considered as joint first
author.

© 2021 International Society for Autism Research, Wiley Periodicals LLC.

1046 wileyonlinelibrary.com/journal/aur Autism Research. 2021;14:1046–1060.

KIM ET AL.
INTRODUCTION
In 2017, 14% of all public school students in the United
States were served by Part B of the Individuals with Dis-
abilities Education Improvement Act (IDEA) (U.S.
Department of Education, 2004). IDEA mandates equity
and accountability in education for children with disabil-
ities. Part B of IDEA recognizes 13 distinct disability cate-
gories based on the assessment of need for specific
educational support and includes among others: autism
spectrum disorder (ASD) and intellectual disability (ID).
Primary special education classifications are made by
school or district staff and informed by educational assess-
ments, but are not medical diagnoses or based on the
Diagnostic and Statistical Manual of Mental Disorders,
5th Edition (DSM-5) diagnoses (American Psychiatric
Association, 2013). State policies governing services for
students with disabilities include guidelines on required
screening and evaluations in addition to disability specific
characteristics that may qualify an individual for a special
education classification, but school districts vary in the
instruments used and their approach to determine classifi-
cations (State Board of Education Department of Public
Instruction Exceptional Children Division, 2018). Further-
more, there is variation around the criteria necessary for
special education classifications for each condition.
In North Carolina for example, while state policy
guidelines for ID classification include specifications on
standard deviation requirements on intelligence tests and
adaptive behavior assessments, ASD classification guide-
lines are less specific. The ASD classification requires
impairments in social communication and the presence of
sensory experiences and/or restricted, repetitive behav-
iors, interests and/or activities but does not operationalize
these characteristics or specify the level of impairment
required (State Board of Education Department of Public
Instruction Exceptional Children Division, 2018). Fol-
lowing screening and evaluations a multidisciplinary
school team determines whether a child is eligible for spe-
cial education services. If the child is deemed eligible, an
Individualized Education Plan (IEP) is then developed to
ensure that a child with an identified disability receives
specialized educational instruction. While students may
have more than one disability, for example ASD with
comorbid ID, the primary disability category should be
the one that causes the most difficulty for the child in the
school setting (Wettach, 2017). Although total student
enrolment in IDEA Part B has remained relatively stable
over the past two decades, the percentage of children
receiving services under the ASD category has risen sig-
nificantly while the percentage of children receiving ser-
vices under the ID category has decreased (Polyak,
Kubina, & Girirajan, 2015; U.S. Department of
Education, 2017). It has been suggested that these trends
represent a degree of diagnostic substitution with ASD
replacing ID disability categorization over time
(Shattuck, 2006).
1047
Racial and ethnic differences in ASD and ID
Data from the Autism and Developmental Disabilities
Monitoring (ADDM) Network, which estimates the
number of children with ASD living in various regions of
the United States and uses a combined methodology
including school reports and review of medical records,
highlights disparities in identification of Black and His-
panic children (Maenner et al., 2020). While ADDM
Network prevalence data indicates similar estimates for
non-Hispanic White and non-Hispanic Black children,
these estimates are lower for Hispanic children. In addi-
tion, while 33% of children with ASD have ID, this
comorbidity is more common in Black and Hispanic chil-
dren as compared to White children (47%, 36%, and
27%, respectively). Furthermore, Black children with
comorbid ID have a later median age at ASD diagnosis
when compared to White children with comorbid ID
(Maenner et al., 2020; Mandell et al., 2009). Data from
the Metropolitan Atlanta Developmental Disabilities
Surveillance Program (MADDSP), which provides cross-
sectional prevalence estimates based on education and
health administrative records, indicates that Hispanic
children are one and a half times as likely, and Black chil-
dren twice as likely to be diagnosed with ID as compared
to White children (Van Naarden Braun et al., 2015). Pre-
vious research suggests that socioeconomic status can sig-
nificantly impact ID rates (Maulik, Mascarenhas,
Mathers, Dua, & Saxena, 2011). These differences may
relate to risk factors associated with living in poverty, in
addition to test biases that may differentially impact
racial/ethnic minorities and English language learners
(Boyle et al., 2011; Camp, Broman, Nichols, &
Leff, 1998; The National Academies of Sciences Engi-
neering and Medicine, 2015). The association between
low socioeconomic status and mild ID has been noted to
be stronger than the association between low socioeco-
nomic status and more severe levels of ID (Drews,
Yeargin-Allsopp, Decoufle, & Murphy, 1995; Durkin,
Schupf, Stein, & Susser, 1998; Harris, 2006).
Implications of rurality
One in five Americans live in rural parts of the United
States as defined by the Census Bureau (Weil, 2019).
Black and Hispanic individuals living in the rural South,
particularly Black single mothers, face some of the
highest poverty rates in the nation (Burton, Mattingly,
Pedroza, & Welsh, 2017). Additionally, poor rural com-
munities often house hazardous waste and landfills that
may pollute the surrounding environment with potential
neurotoxins like lead (Burton, Lichter, Baker, &
Eason, 2013). Rural families with children who have dis-
abilities experience numerous healthcare and education
barriers, including difficulty accessing professionals
trained in assessment, educational support, and
1048
disability-specific intervention (Antezana, Scarpa, Val-
despino, Albright, & Richey, 2017). In addition, rural set-
tings have fewer service providers per capita, and lower
education levels among residents, with some rural school
districts receiving 50% less federal Title 1 funding per stu-
dent than urban, Title 1 schools (Gutierrez, 2016;
Hartley, 2004). Schools in rural areas may have limited
availability of testing resources and staff with ASD-
specific knowledge which may impact special education
service classification (Antezana et al., 2017). Individuals
with ASD who live in rural areas may therefore be at a
higher risk of not receiving disability-specific supports
which may impact long-term educational and functional
outcomes.
Recent findings in North Carolina
North Carolina is one of 11 states represented in the
ADDM Network (Maenner et al., 2020). While the most
recent data from this network indicates the prevalence of
ASD is higher in Non-Hispanic Black children (27.9%)
compared to Non-Hispanic White children (23.3%), out
of the four counties in central North Carolina from
which the data is drawn, only one is rural, and is located
adjacent to a regional city/sub-urban county and an
urban county which may suggest greater access to profes-
sionals trained in assessment and educational supports. A
recent study by Howard et al. examined the role of race
and socioeconomic status on ASD and ID educational
classification in North Carolina (Howard et al., 2020).
The study found that rates of ASD or ID student classifi-
cation were primarily driven by median county house-
hold income. A higher median county household income
was associated with a greater proportion of students in
the county with an ASD classification and a lower pro-
portion of students with an ID classification. Further-
more, they found that a greater proportion of Black
students living in the county was associated with a higher
proportion of students with an ID classification. In addi-
tion, the proportion of students with ID and ASD educa-
tional classifications varied considerably by county.
Howard et al. speculated that varying rates of ASD and
ID classifications were due to school-level and county-
level disparities in the availability of diagnostic and treat-
ment resources.
Their analysis however was only done at the county
level with a relatively limited dataset. More detailed
county-level and individual-level characteristics would
allow for further exploration of the impact of race/ethnic-
ity, socioeconomic economic status, rurality and health
service availability on ASD and ID educational classifi-
cation. This type of research could identify factors driv-
ing disparities in educational classification that impact
opportunities for children to receive disability-specific
services and supports (Bitterman, Daley, Misra, Car-
lson, & Markowitz, 2008). North Carolina is an ideal
KIM ET AL.
context to examine these issues because much of the state
is rural and the percentage of Black residents is high
(22.2%) compared to the national average (13.4%;
U.S. Census Bureau, 2019).
Study aims
The current study examines North Carolina education
data to determine whether rurality, race/ethnicity, and
other important indicators of low resource availability
are associated with disparities in primary educational
classifications of ASD and ID. First, we examine whether
rurality and the proportion of African Americans in a
county are associated. Then, we examine whether the
probability of students having a primary classification of
ID versus ASD differs by race and rurality. We hypothe-
sized that the probability of students being classified as
having mild, moderate or severe ID over ASD would be
significantly higher for African American, Hispanic, and
other students living in rural areas compared to White
students. We delineated severity of ID in our hypothesis
due to prior evidence that socioeconomic status is more
strongly associated with mild levels of ID compared to
more severe levels of ID classification (Drews
et al., 1995; Harris, 2006). Furthermore, the effects of
limited English proficiency, child sex, provider availabil-
ity and low resource availability are also considered.
METHODS
Data
The analysis dataset was constructed using data obtained
from: The North Carolina Education Research Data
Center (NCERDC); (a) The Cecil G. Sheps Center for
Health Services Research (SC-HSR); (b) The North Car-
olina Rural Center (NC-RC); (c) The North Carolina
Office of State Budget and Management (NC-OSBM);
and (d) The North Carolina Department of Environmen-
tal Quality Online GIS website (NC-DEQ). Specifically,
the current study obtained the following datasets:
(a) Students receiving special education services, for the
academic year 2017–2018 from the NCERDC;
(b) School records and characteristics, collected in the
year 2015 from the NCERDC; (c) North Carolina
Licensed Health Professionals data collected for 2018
from the SC-HSR; (d) Classification of urban, rural or
regional city/sub-urban counties from the NC-RC;
(e) Percentage of African Americans living in North Car-
olina by county, as of July, 2018, from the NC-OSBM;
and (f) North Carolina county boundaries shapefile from
the NC-DEQ.
The “special education services” dataset and the
school-level dataset from the NCERDC were merged
using unique school-level identifiers. North Carolina
KIM ET AL.
Licensed Health Professionals data from the SC-HSR
and the classification of counties from the NC-RC were
merged with the other datasets using county-level identi-
fiers. Percentages of African Americans living in North
Carolina counties were merged with the shapefile for
North Carolina county boundaries. The number of
observations relevant for analysis was 38,336 students
with either ASD or ID classification in North Carolina.
Variables
Primary classifications of ASD and mild, moderate or
severe ID were used to construct binary outcome vari-
ables; in North Carolina, these are the only three catego-
ries for ID classification. These variables were extracted
from the NCERDC dataset, and identify student primary
disability category as documented on their IEP. There
were two binary outcome variables: (a) Students classi-
fied as having ASD as the referent group (value of 0) to
whom students classified as having mild ID were being
compared (value of 1); and (b) students classified as hav-
ing ASD as the referent group (value of 0) to whom stu-
dents classified as having moderate or severe ID were
being compared (value of 1).
Several student-level and county-level characteristics
were included as important predictors for classification
into either ASD or ID. At the student-level, level of
schooling, race, sex and limited English language profi-
ciency were included. Student’s level of schooling was
included because we suspect classifications of ID to be
disproportionately higher at younger ages. Student’s level
of schooling was categorized as being in Elementary,
Middle or High school, from age 8 to 22 years. For stu-
dents in elementary school, those below age 8 were
excluded because developmental delay, a disability cate-
gory applicable only to children ages three through
7 years, may include children with either ASD or ID
(State Board of Education Department of Public Instruc-
tion Exceptional Children Division, 2018). The upper age
limit for “exceptionality” category is 21 years. However,
in the analysis sample, there were some high school stu-
dents who were 22 years old (<1% of the analysis sam-
ple). Student’s race/ethnicity was a main predictor of
interest and it was categorized as either Non-Hispanic
White, Non-Hispanic Black or Hispanic, and others. In
the “others” category of race/ethnicity, non-Hispanic
Hawaiians/Pacific Islanders, non-Hispanic Asians, non-
Hispanic American Indians/Alaskans, Hispanic Hawai-
ians/Pacific Islanders, Hispanic Asians, Hispanic Ameri-
can Indians/Alaskans, and different combinations of
these races/ethnicities with Whites and Blacks were
included. Student’s sex, categorized as male or female,
was included because there is evidence of male-to-female
ratio for ASD diagnosis being skewed towards males
(Loomes, Hull, & Mandy, 2017). Student’s limited
English language proficiency was included because of test
1049
biases that may differentially impact non-English-speaking
children (The National Academies of Sciences Engineering
and Medicine, 2015). This variable was categorized as
either yes or no. At the county-level, classification of resi-
dence, percent of students who are economically disadvan-
taged, and number of relevant healthcare professionals
(per 10,000 people) with primary practice locations in the
county were included. Classification of residence was a
main predictor of interest representing varying levels of
resource availability and it was categorized as living in
either an urban county, a rural county or a regional city or
a sub-urban county in North Carolina. According to the
NC Rural Center, urban counties were defined as having
an average population density that exceeded 750 people
per square mile. Rural counties were defined as having an
average population density of 250 people per square mile
or less. Regional city and suburban counties were defined
as having an average population density between 250 and
750 people per square mile (NC Rural Center, 2014). Per-
cent of students who are economically disadvantaged was
created as a continuous variable, where the number of stu-
dents from families with income up to 185% of the federal
poverty level was divided by the total number of students
in the county. This variable serves as a proxy for the gen-
eral socioeconomic status of residents at the county level.
Individual socioeconomic status was not included due to
lack of relevant variables in the dataset. Number of rele-
vant healthcare professionals (per 10,000 people) with pri-
mary practice locations in the county was also a
continuous variable. The numbers of licensed providers
practicing psychology, general pediatrics, pediatrics with
nonsurgical specialties, child and adolescent psychiatry,
general psychiatry, or neurology were added to represent
the relevant healthcare service availability in each county.
Both continuous variables were centered around their
grand means.
Analysis
First, urban, rural, and sub-urban classifications
(Figure 1a), percentages of African Americans by county
(Figure 1b), percentages of students with ASD by county
(Figure 1c), and percentages of students with ID by
county (Figure 1d) were all merged with the shapefile for
North Carolina county boundaries to create descriptive
maps using the QGIS program version 3.8.3 (QGIS
Development Team, 2019).
Second, a simple descriptive analysis was conducted
with the study variables (Table 1). Then, multilevel logistic
regression models were estimated in Stata 15.1 where each
model examined two separate outcomes (mild ID
vs. ASD; moderate or severe ID vs. ASD). Missing data
techniques were not used because only about 2% of the
data were missing in the final analyses. Model 1 was a null
model where only the intercept and the random effects at
the school-level and at the county-level were included.
1050 KIM ET AL.

F I G U R E 1 (a) Urban, rural, and

suburban classification for
NC. (b) Percentage of African-American
population per NC County. (c) Percentage
of students classified as ASD by NC
County. (d) Percentage of students
classified as ID by NC County

Model 2 included all of the study variables and the interac-
tion between student’s race/ethnicity and residence in addi-
tion to the school-level and county-level random effects.
Robust standard errors were estimated. For the null model
(Model 1), the variance partitioning coefficients were also
calculated. Due to the outcome variables being binary, the
residual variance was estimated as π3 , assuming that there
2
is an unobserved continuous distribution underlying the
binary outcome variables. See Table 2 for the estimated
regression coefficients for the models.
In addition, the predicted probabilities (and their 95%
confidence intervals) for being classified as having mild
ID relative to being classified as having ASD and the
predicted probabilities (and their 95% confidence inter-
vals) for being classified as having moderate or severe ID
relative to being classified as having ASD were calculated
KIM ET AL. 1051

TABLE 1 Descriptive analysis of the study variables

Autism Mild, moderate or severe IDa

N % N %

Totalsb 21,508 – 16,828 –

Student’s level of schooling
Elementary school (age 8 or older) 6398 39.38% 5218 31.94%
Middle school 4463 27.47% 4459 27.29%
High school 5384 33.14% 6660 40.77%
Student’s Race
White (Non-Hispanic) 12,171 56.59% 6517 38.73%
Black (Non-Hispanic) 6034 28.05% 7541 44.81%
Hispanic & others 3303 15.36% 2770 16.46%
Student’s sex
Male 17,923 83.33% 9830 58.41%
Female 3585 16.67% 6998 41.59%
Student’s limited English proficiency
Yes 1198 5.57% 1629 9.68%
No 20,310 94.43% 15,199 90.32%
Classification of residencec
Urban 8471 39.88% 4306 25.79%
Rural 7638 35.96% 8406 50.35%
Regional City or Sub-Urban Areas 5132 24.16% 3983 23.86%
N Mean N Mean
(SD) (SD)
Percent of Students who are economically disadvantagedd 21,241 44.16 16,695 47.15
(8.58) (8.26)
Number of relevant healthcare professionals Per 10,000 21,241 6.688 16,695 5.041
populatione (7.012) (5.504)
Note: Column percentages add up to 100%.
a
ID stands for intellectual disability.
b
Only those who had primary classifications of either Autism, mild intellectual disability or moderate or severe intellectual disability were included in the study sample for
analysis.
c
Classification of residence was determined by the definitions provided by the NC Rural Center. Source: https://www.ncruralcenter.org/about-us/.
d
“Economically disadvantaged” students are from families with income up to 185% of the federal poverty level.
e
Number of health providers (per 10,000 population by county) in Neurology, General Pediatrics, Pediatrics with nonsurgical specialties, Child & Adolescent Psychiatry,
General Psychiatry, and Psychology were added as a summary measure. This information is publicly available at the UNC Sheps Center’s “NC Health Professions Data
System (HPDS)”. Source: https://www.shepscenter.unc.edu/data/.

(Table 3). It is important to note that these predicted
probabilities were estimated for students with specific
conditions. For Model 2, predicted probabilities can be
interpreted for male, elementary school students 8 years
old or older with English proficiency, living in a rural
county, where the percentage of students who are eco-
nomically disadvantaged is about average in comparison
to other NC counties and living in a county where there
is about an average number of relevant healthcare profes-
sionals in comparison to other NC counties. These spe-
cific conditions were selected because each condition
represented the largest proportion in the original sample.
The predicted probabilities were then plotted for visual
representation (Figure 2). For the non-interacted
covariates in the models, average marginal effects and
discrete first-differences and their 95% confidence inter-
vals were estimated and shown in Table 4. Average
marginal effects can be interpreted as percentage point
changes in the probability of the outcome due to one unit
change in the continuous predictor. Effects from discrete
first-differences can be interpreted as percentage point
differences in the predicted probability of the outcome
between the referent category and the comparison cate-
gory (of the categorical predictor).
RESULTS
Geographic distribution of African Americans,
students with ASD, and students with ID
Eighty of 100 counties in North Carolina are considered
rural. Only 20 counties are considered as either urban
counties, regional cities or sub-urban counties
1052 KIM ET AL.

TABLE 2 Estimated regression coefficients from the models

Model 2: Includes interaction between

Model 1: Null model student’s race and residence
Moderate or severe Moderate or severe
Mild ID (vs. autism) ID (vs. autism) Mild ID (vs. autism) ID (vs. autism)

Observations 32,605 26,572 27,062 21,176

Student-level characteristics
Intercept −0.472*** −1.853*** −2.041*** −2.794***
(−0.647, −0.298) (−2.059, −1.647) (−2.403, −1.678) (−3.098, −2.490)
Student’s level of schooling
Elementary school (age 8 or older) – –
Middle school 0.187*** 0.320***
(0.097, 0.278) (0.195, 0.446)
High school 0.302*** 0.800***
(0.192, 0.411) (0.644, 0.955)
Student’s Race
White (Non-Hispanic) – –
Black (Non-Hispanic) 1.214*** 0.324*
(0.994, 1.435) (0.049, 0.599)
Hispanic & others 0.329*** 0.256***
(0.244, 0.414) (0.112, 0.400)
Student’s Race X
Classification of residence (interactions)
White (Non-Hispanic) X – –
Urban residence
White (Non-Hispanic) X – –
Rural residence
White (Non-Hispanic) X – –
Regional City or Sub-Urban residence
Black (Non-Hispanic) X – –
Urban residence
Black (Non-Hispanic) X 0.064 0.267
Rural residence (−0.191, 0.320) (−0.046, 0.580)
Black (Non-Hispanic) X 0.143 0.612***
Regional City or Sub-Urban residence (−0.176, 0.463) (0.279, 0.945)
Hispanic & others X – –
Urban residence
Hispanic & others X 0.125 0.103
Rural residence (−0.166, 0.417) (−0.143, 0.350)
Hispanic & others X −0.207 0.125
Regional City or Sub-Urban residence (−0.455, 0.041) (−0.106, 0.355)
Student’s limited English proficiency
No – –
Yes 0.976*** 0.677***
(0.781, 1.171) (0.531, 0.822)
Student’s sex
Male – –
Female 1.425*** 1.551***
(1.356, 1.494) (1.479, 1.624)
Higher-level characteristics
Classification of residencea
Urban – –
Rural 0.700** 0.279
(0.280, 1.119) (−0.089, 0.647)
Regional City or Sub-Urban areas 0.663** 0.006
(0.229, 1.098) (−0.362, 0.374)
(Continues)
KIM ET AL. 1053

TABLE 2 (Continued)

Model 2: Includes interaction between

Model 1: Null model student’s race and residence
Moderate or severe Moderate or severe
Mild ID (vs. autism) ID (vs. autism) Mild ID (vs. autism) ID (vs. autism)

Percent of students who are economically 0.027** 0.016

disadvantaged (centered) b (0.009, 0.044) (−0.001, 0.033)
Number of relevant healthcare professionals per −0.032*** −0.021**
10,000 population (−0.047, −0.017) (−0.035, −0.007)
(centered)c
Variance of random effects
School-level random effect 0.937 1.679 0.519 1.223
(0.782, 1.122) (1.263, 2.232) (0.407, 0.662) (0.875, 1.710)
County-level random effect 0.617 0.412 0.308 0.186
(0.443, 0.860) (0.234, 0.725) (0.208, 0.456) (0.090, 0.382)
Variance partitioning coefficientd
School-level 0.193 0.312
County-level 0.127 0.077
Number of clusters
School-level 2574 2487 2443 2324
County-level 100 100 100 100
Note: It is important to remember that only those who had primary classifications of either Autism, mild intellectual disability or moderate or severe intellectual disability
were included in the study sample for analysis. The estimated covariate effects on the predicted probabilities of mild intellectual disability or moderate or severe
intellectual disability are in relation to the probability of being classified as Autism (Mild ID or Moderate/Severe ID = 1; Autism = 0). Referent categories are represented
by dashes (−). The 95% confidence intervals are in parentheses.
a
Classification of residence was determined by the definitions provided by the NC Rural Center. Source: https://www.ncruralcenter.org/about-us/.
b
“Economically disadvantaged” students were those from families with income up to 185% of the federal poverty level. This variable was centered around the grand mean.
c
Number of health providers (per 10,000 population by county) in Neurology, General Pediatrics, Pediatrics with nonsurgical specialties, Child & Adolescent Psychiatry,
General Psychiatry and Psychology were added as a summary measure. This variable was also centered around the grand mean. This information is publicly available at
the UNC Sheps Center’s “NC Health Professions Data System (HPDS)”. Source: https://www.shepscenter.unc.edu/data/.
d
The variance partitioning coefficients were calculated by dividing the level-specific random effect by the sum of the random effects for each level and the residual
variance, (π2/3).
*
p < 0.05; **p < 0.01; ***p < 0.001.

TABLE 3 Adjusted predictions of mild ID and moderate or severe ID versus ASD

Mild ID (vs. ASD) Moderate or severe ID (vs. ASD)

Predicted probabilities 95% CI Predicted probabilities 95% CI

White (Non-Hispanic)
Urban residence 0.145 (0.103, 0.187) 0.093 (0.072, 0.113)
Rural residence 0.240 (0.207, 0.273) 0.115 (0.097, 0.134)
Regional City or Sub-Urban residence 0.235 (0.186, 0.283) 0.093 (0.072, 0.115)
Black (Non-Hispanic)
Urban residence 0.331 (0.277, 0.384) 0.119 (0.098, 0.140)
Rural residence 0.487 (0.444, 0.530) 0.177 (0.147, 0.207)
Regional City or Sub-Urban residence 0.496 (0.421, 0.570) 0.186 (0.151, 0.221)
Hispanic and others
Urban residence 0.186 (0.136, 0.236) 0.113 (0.098, 0.129)
Rural residence 0.319 (0.250, 0.389) 0.150 (0.119, 0.182)
Regional City or Sub-Urban residence 0.254 (0.187, 0.321) 0.125 (0.091, 0.160)
Note: The adjusted predictions were for elementary school-aged male students with English proficiency who live in a county with average percentage of students who are
economically disadvantaged (NC average) and live in a county with average number of health care professionals (NC average).
1054
F I G U R E 2 (a) Adjusted predictions of mild ID versus ASD by
student’s race/ethnicity and residence. (b) Adjusted predictions of
moderate/severe ID versus ASD by student’s race/ethnicity and
residence
(Figure 1a). As for the percentage of African Americans
living in each county, the northeastern part of North Car-
olina in particular had the highest percentages of African
Americans between 34.4 and 61.4% (Figure 1b). The
highest percentages of students with ASD were found in
urban counties, regional cities, and suburban counties
(Figure 1c). On the contrary, the highest percentages of
students with ID were primarily found in the eastern part
of North Carolina, the same rural counties that coincide
with a high African American population (Figure 1d).
When county-level percentages of students classified as
having ASD, percentages of students classified as having
mild ID, and percentages of students classified as having
moderate or severe ID were separately regressed on rural-
ity, rural counties showed significantly lower percentages
of students classified as having ASD and significantly
higher percentages of students classified as having mild
ID compared to urban counties. Rurality was not signifi-
cantly associated with students being classified as having
moderate or severe ID (not shown in Tables). The
KIM ET AL.
associations of rurality, race/ethnicity and patterns of
ASD/ID prevalence revealed from the above geographic
and simple regression analyses led to more advanced ana-
lyses below.
Descriptive background of students with ASD
and students with ID
Among students with a primary classification of ASD,
nearly 40% were in elementary school (age 8 and above),
27% were in middle school and 33% were in high school.
The highest percentage of students with ASD were non-
Hispanic Whites (57%). Twenty-eight percent were non-
Hispanic Blacks and 15% were Hispanics or others. The
majority were male (83%) and were proficient in the
English language (94%). Close to 40% lived in urban
counties, 36% lived in rural counties and the remaining
24% lived in regional cities or sub-urban counties. On
average, these students were living in counties where 44%
of the total students were considered to be economically
disadvantaged. In addition, there were an average of
about 6.7 relevant healthcare professionals per 10,000
people in the counties of residence of these students
(Table 1).
Among students with a primary classification of
either mild, moderate or severe ID, 32% were in elemen-
tary school (age 8 and above), 27% were in middle school
and 41% were in high school. The highest percentage of
these students were non-Hispanic Blacks at 45%,
followed by non-Hispanic Whites at 39% and Hispanics
or others at 16%. More than half of these students were
male (58%) and the majority were proficient in the
English language (90%). About half of these students also
lived in rural counties (50%) and nearly equal numbers of
students lived in either urban or regional cities/sub-urban
counties. On average, these students were living in
counties where nearly 47% of the total students were con-
sidered to be economically disadvantaged. In addition,
there were an average of about five relevant healthcare
professionals per 10,000 people in the counties of resi-
dence of these students (Table 1).
Predicted probabilities of mild ID and moderate/
severe ID versus ASD by Student’s race/ethnicity
and residence
For all elementary students regardless of their race/eth-
nicity, those living in urban counties had significantly
lower probability of being classified as having mild ID
versus ASD than those living in rural counties. For non-
Hispanic Black elementary students, those living in urban
counties had significantly lower probabilities of being
classified as having mild ID versus ASD than those living
in regional cities or sub-urban counties. In addition, non-
Hispanic Black elementary students, regardless of their
KIM ET AL. 1055

TABLE 4 Estimated effects for noninteracted covariates from the models

Model 2: Includes interaction between student’s race and residence

Mild ID (vs. autism) Moderate or severe ID (vs. autism)

Effects 95% CI Effects 95% CI

Student’s level of schooling

Elementary school – – – –
(age 8 or older)
Middle school 0.033*** (0.017, 0.048) 0.038*** (0.023, 0.053)
High school 0.053*** (0.034, 0.072) 0.103*** (0.083, 0.124)
Student’s limited English proficiency
No – – – –
Yes 0.175*** (0.142, 0.208) 0.096*** (0.073, 0.118)
Student’s sex
Male – – – –
Female 0.266*** (0.251, 0.282) 0.235*** (0.214, 0.255)
Percent of students who are economically disadvantaged 0.0046** (0.0017, 0.0076) 0.0021 (−0.000, 0.0043)
(centered)a
Number of relevant healthcare professionals per 10,000 −0.006*** (−0.008, −0.003) −0.003** (−0.005, −0.001)
population (centered)b
Note: It is important to remember that only those who had primary classifications of either Autism, mild intellectual disability or moderate or severe intellectual disability
were included in the study sample for analysis. The estimated average marginal/discrete first-difference effects on the predicted probabilities of mild intellectual disability
or moderate or severe intellectual disability are in relation to the probability of being classified as Autism (Mild ID or Moderate/Severe ID = 1; Autism = 0). Referent
categories are represented by dashes (−).
a
“Economically disadvantaged” students were those from families with income up to 185% of the federal poverty level. This variable was centered around the grand mean.
b
Number of health providers (per 10,000 population by county) in Neurology, General Pediatrics, Pediatrics with non-surgical specialties, Child & Adolescent Psychiatry,
General Psychiatry and Psychology were added as a summary measure. This variable was also centered around the grand mean. This information is publicly available at
the UNC Sheps Center’s “NC Health Professions Data System (HPDS)”. Source: https://www.shepscenter.unc.edu/data/.
**p < 0.01; ***p < 0.001.

residence, had significantly higher probabilities of being
classified as having mild ID versus ASD than non-
Hispanic White elementary students. Hispanic and others
living in rural counties also had significantly higher prob-
ability of being classified as having mild ID versus ASD
than non-Hispanic White elementary students living in
urban areas. In comparing elementary students living in
rural counties and those living in regional cities or sub-
urban counties, the probabilities of being classified as
having mild ID versus ASD were not significantly differ-
ent (Table 3 and Figure 2).
As for the probability of being classified as having
moderate or severe ID versus ASD, non-Hispanic Black
elementary students living in urban counties had signifi-
cantly lower probability than those living in rural,
regional cities, or sub-urban counties. In addition, non-
Hispanic Black elementary students living in rural,
regional cities or sub-urban counties had significantly
higher probabilities of being classified as having moder-
ate or severe ID versus ASD than non-Hispanic White
elementary students living in any residential category
(urban, rural, regional city, or sub-urban county). His-
panic and others living in rural counties also had signifi-
cantly higher probability of being classified as having
moderate or severe ID versus ASD than non-Hispanic
White students in urban counties and in regional cities or
sub-urban counties. Among non-Hispanic White elemen-
tary students and among Hispanic and others, probabili-
ties of being classified as having moderate or severe ID
versus ASD did not significantly differ by residence
(Table 3 and Figure 2b).
The effects of other covariates
Students in middle school had about 3% points higher
probability of being classified as having mild ID ver-
sus ASD and about 4% points higher probability of
being classified as having moderate or severe ID ver-
sus ASD than students in elementary school (age 8 or
older). Students in high school had about 5% points
higher probability of being classified as having mild
ID versus ASD and about 10% points higher probabil-
ity of being classified as having moderate or severe ID
versus ASD than students in elementary school (age
8 or older).
Students with limited English proficiency had signifi-
cantly higher probability of being classified as having
mild ID versus ASD than students with English profi-
ciency, by about 18% points. Students with limited
English proficiency also had significantly higher proba-
bility of being classified as having moderate or severe ID
1056
versus ASD than students with English proficiency, by
about 10% points.
Female students, compared to male students, had sig-
nificantly higher probabilities of being classified as hav-
ing mild ID versus ASD and also being classified as
having moderate or severe ID versus ASD (about 27%
points higher and 24% points higher, respectively).
On average, for every one-unit increase in the percent-
age of students who are considered economically disad-
vantaged in the county, the probability of being classified
as having mild ID versus ASD increased by about 0.5%
points and the probability of being classified as having
moderate or severe ID versus ASD increased by about
0.2% points (although not significant). Also, on average,
with one additional relevant healthcare professional per
10,000 people in the county, the probability of being clas-
sified as having mild ID versus ASD decreased by about
0.6% points and the probability of being classified as hav-
ing moderate or severe ID versus ASD decreased by
about 0.3% points (Table 4). Also, see Table 2 for all of
the raw coefficients.
DISCUSSION
The current study examined education data to determine
the impact of rurality, race/ethnicity, and low resource
availability on primary educational classifications of
ASD and ID in North Carolina. Geographic variation in
the proportion of children with a primary educational
classification of ID was found, such that the majority of
students with ID were in the eastern part of the state, a
region where most African Americans reside. In addition,
rural counties had fewer students with a primary ASD
classification and a greater number of students with a
classification of mild ID compared to urban counties.
Racial/ethnic variation in the proportion of children with
a primary educational classification of ASD and ID were
seen, such that the majority of students with ASD were
non-Hispanic Whites, while the majority of students with
ID were non-Hispanic Blacks. Furthermore, a significant
interaction of rurality and race/ethnicity was noted. We
initially hypothesized that the probability of students
being classified as having mild, moderate or severe ID
over ASD would be significantly higher for minority stu-
dents living in rural areas compared to White students.
Our main findings were consistent with our hypothesis.
In addition to confirming our hypothesis, we also found
that Non-Hispanic Black students living in regional cities
or sub-urban counties had significantly higher probabili-
ties of being classified as having mild, moderate or severe
ID versus ASD than non-Hispanic White students. His-
panic and other students living in rural counties also had
significantly higher probabilities of being classified as
having mild, moderate or severe ID versus ASD than
non-Hispanic White students living in urban counties.
Limited English proficiency, living in economically
KIM ET AL.
disadvantaged counties, and living in counties with few
healthcare professionals was associated with higher prob-
abilities of ID versus ASD classification. These findings
collectively suggest that in North Carolina primary edu-
cational classification of ASD and ID may be impacted
by county of residence, race/ethnicity, and access to eco-
nomic and professional resources.
In our study, we found urban–rural differences in pri-
mary educational classification of ASD and
ID. Regardless of race/ethnicity those living in urban
counties were less likely to have a primary educational
classification of mild ID versus ASD than those living in
rural counties. Data from the National Survey of Chil-
dren’s Health, a population-based epidemiological study
that relies on parent report of ASD, documented similar
rates of ASD in urban and rural communities (National
Survey of Children’s Health, 2007). Therefore, urban–
rural differences in primary educational classification of
ASD may relate to school service availability, in addition
to awareness and recognition of the condition among the
lay public and professional groups (Vassos, Agerbo,
Mors, & Pedersen, 2016; Williams, Higgins, &
Brayne, 2006). ASD diagnostic and treatment services
are among the most expensive services of those deployed
to support children with neurodevelopmental disabilities
and rural schools in the U.S. are often underfunded and
have limited access to professional development opportu-
nities (Antezana et al., 2017; Buescher, Cidav, Knapp, &
Mandell, 2014; Public Schools First NC, 2020). These
two facts in combination may result in less well devel-
oped ASD services in schools in rural communities.
Another challenge facing rural schools are high levels
of community poverty (Burton et al., 2017). In our study,
we found that greater economic disadvantage was associ-
ated with higher probabilities of ID versus ASD educa-
tional classification. Poverty has been reported to be a
consistent risk factor for ID, with the association between
poverty and mild ID being considerably stronger than
the association with more severe levels of ID (Drews
et al., 1995; Emerson, 2007). Furthermore, ID has been
reported to occur more frequently in rural communities
than in urban settings (Lai, Tseng, Hou, & Guo, 2012;
Sondenaa, Rasmussen, Nottestad, & Lauvrud, 2010;
Vassos et al., 2016). National education data trends indi-
cate a significant increase in the percentage of children
receiving a primary educational classification of ASD
and a decrease in the percentage of children receiving a
primary education classification of ID—a trend that has
in part been attributed to diagnostic substitution (Polyak
et al., 2015; U.S. Department of Education, 2017). Our
results suggest over-representation of the primary educa-
tion classification of mild ID in rural counties and may
indicate that ASD-ID diagnostic substitution is not
occurring to the same degree in rural communities as
national data would suggest.
In our study, we found student race/ethnicity, English
proficiency, and the interaction of race/ethnicity and
KIM ET AL.
rurality to be associated with differences in primary edu-
cational classification of ASD and ID. Disproportionate
representation of racial/ethnic minority students has been
reported in education data (U.S. Department of Educa-
tion Office of Special Education Programs, 2018). In
2017–2018, 16% of Black students nationwide were iden-
tified as having disabilities, compared to 14% of White
students. Differences in identification rates vary by dis-
ability category, with some categories, including ID and
ASD, exhibiting larger proportional differences (U.S.
Department of Education, National Center for Educa-
tion Statistics, & American Institutes for
Research, 2018). For example, the percentage of students
served under IDEA who received services for ID was
highest for Black students (9%); the percentages for stu-
dents of the other races/ethnicities shown ranged from
5 to 7%. Furthermore, the percentage of students served
under IDEA who received services for ASD was 10% for
White students; and the percentages for Black was 7%.
Importantly, when academic achievement and factors
associated with economic disadvantage are statistically
controlled for, some studies suggest that minority stu-
dents are actually underrepresented in special education
(Morgan, Farkas, Hillemeier, & Maczuga, 2017; Morgan
et al., 2015). Using a large student-level, nationally rep-
resentative dataset, Morgan and colleagues reported
that children who are Black or Hispanic had low odds
of having a primary educational classification of ASD
even without controlling for confounds; but ID under
identification attributable to race/ethnicity was not evi-
dent until individual-level achievement was statistically
controlled (Morgan et al., 2017). Racial/ethnic differ-
ences in primary educational classification of ASD and
ID may therefore relate to greater exposure to factors
that disproportionately increase risk for disabilities, for
example poverty, low birthweight, and lead exposure, in
addition to disparities in access to community and
school services (Durkin et al., 2017; García, 2015;
Morsy & Rothstein, 2015).
Primary special education eligibility classifications
matter because, for individuals with ASD for example,
implementation of a quality IEP that includes measur-
able social communication goals tracked over time is a
strong predictor of functional outcomes (Ruble &
McGrew, 2013). Additionally, there is evidence to sug-
gest that having a primary ASD classification may
impact the number of services a child receives and the
amount of time a child spends in special education set-
tings (Bitterman et al., 2008). Studies suggest that IEP
goals for culturally and linguistically diverse students
with ASD are less likely to include social communica-
tion goals than other groups of students (Liptak
et al., 2008; Mandell et al., 2009; St. Amant, Schrager,
Pena-Ricardo, Williams, & Vanderbilt, 2018). For
example, a study conducted by St. Amant et al. found
that children whose parents spoke English as a primary
language were significantly more likely to have an IEP
1057
that included social communication goals and received
more hours of direct service compared to children
whose parents’ primary language was not English
(St. Amant et al., 2018).
Differences in primary educational classification
based on urban–rural divide, race/ethnicity, and resource
availability are important to understand as they may
point to disparities that could have important policy and
service implications. Disparities are differences in out-
comes or service use that adversely impact a particular
group of people who historically have been excluded or
discriminated against and experience barriers based on
their race/ethnicity, socioeconomic status, disability, or
geographic location (U.S. Department of Health and
Human Services, 2008). Frameworks have been devel-
oped that support research to detect, understand, and
address disparities (Kilbourne, Switzer, Hyman,
Crowley-Matoka, & Fine, 2006; National Institute on
Minority Health and Health Disparities, 2017). Impor-
tantly, frameworks such as the National Institute on
Minority Health and Health Disparities Research Frame-
work span various domains (biological, behavioral, phys-
ical/built environment, sociocultural environment, and
system) and levels of influence (individual, interpersonal,
community, and societal) (National Institute on Minority
Health and Health Disparities, 2017). If differences in
primary educational classification relate to unequal
access to assessment and intervention services based on
geographic location or resource availability at an individ-
ual and community level, these types of disparities sug-
gest the need for policies and specific implementation
strategies to support equitable access to resources. Inter-
estingly, large epidemiological studies in Sweden and
France, countries with universal access to ASD diagnoses
and services unimpeded by economic barriers, found no
association between socioeconomic advantage and ASD
diagnosis, which highlights the importance of under-
standing and dismantling structural access barriers
(Delobel-Ayoub et al., 2015; Rai et al., 2012).
There are limitations to the study. We assessed pri-
mary classifications of ASD and ID and treated them as
mutually exclusive. We recognize that differences identi-
fied in the primary educational classification of ASD and
ID in our study may only reflect differences in placement
of a classification as primary. But while students may
have more than one disability, the primary eligibility cat-
egory should be the one that causes the most impairment
in the school setting (Wettach, 2017). Hence, the implica-
tions of our findings should still hold significance. Due to
the data, we were able to access for this manuscript we
did not include individual socioeconomic status in our
models. Instead, we included contextual measures that
reflect resource and service availability in the area. The
study was conducted in North Carolina. While study
results may have important policy and service implica-
tions beyond North Carolina’s borders, it is important to
acknowledge that the results may not apply to different
1058
states or regions with different geographic and racial/eth-
nic compositions.
Our findings build on those of Howard et al. who
recently conducted analyses using county-level data only,
and reported that rates of ID and ASD classification in
the education system in North Carolina varied by county
and as a function of race and economic disadvantage
(Howard et al., 2020). Our analyses included more
detailed county-level and individual-level characteristics
and suggest that in North Carolina primary educational
classification of ASD and ID may be impacted by county
of residence, race/ethnicity, and access to economic and
professional resources. Future research may benefit from
integrating disparity frameworks to understand differ-
ences in primary educational classifications of ASD and
ID in the context of race/ethnicity and rurality
(Kilbourne et al., 2006; National Institute on Minority
Health and Health Disparities, 2017). This approach
could bring a deeper understanding of specific character-
istics of rural communities, including the educational set-
ting, and the interaction of these characteristics with
personal, social/cultural and environmental factors. This
approach could elucidate strategies by which populations
that are most vulnerable can be effectively targeted.
Strategies may include an increase in the number of dis-
ability specialists in rural communities and/or profes-
sional development opportunities with ongoing
supervision and structural supports. Rapidly evolving
technology including telehealth may help facilitate
increased access to evidence-based services in rural com-
munities. For example, emerging research on caregiver-
mediated tele-assessment, in which diagnostic assessment
activities are conducted by caregivers in their home set-
tings with their child, while being coached online by
remote providers, can expand access to groups impacted
by disparities (Juarez et al., 2018; Narzisi, 2020; Wagner
et al., 2020). Additionally, because disparities manifest
through complex interactions between environmental,
socioeconomic and system-level factors, reduction in
these disparities will require broader approaches that
address structural determinants (Brown et al., 2019).
A CK NO W L E D G M E N T S
The authors would like to acknowledge generous support
from multiple funding sources: Dr. Eunsoo Timothy Kim
was supported by the Global Mental Health Initiative at
the Duke Global Health Institute. Dr. Lauren Franz was
supported by NIMH 5K01MH104370 and NIMH
1R21MH120696. Dr. Danai Kasambira Fannin was
supported by P20 MD000175-13, National Institute on
Minority Health and Health Disparities NCCU Center
for Translational Health Equality Research (CTHER).
Dr. Jill Howard and Dr. Gary Maslow were supported
by the ARC of North Carolina and the state of North
Carolina. We would also like to thank Dr. Yu Bai (PhD),
a statistician at the Duke Center for Child and Family
Policy for providing data support.
KIM ET AL.
CONFLICT OF INTEREST
Dr. Jill Howard has served as an advisory board speaker
for Roche. We declare no other conflicts of interest.
ETHICS ST ATE ME NT
This study received ethical review and approval by the
Duke University Campus Institutional Review Board
(#2018-0438).
OR CID
Eunsoo Timothy Kim https://orcid.org/0000-0003-4035-
5917
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How to cite this article: Kim ET, Franz L,
Fannin DK, Howard J, Maslow G. Educational
classifications of autism spectrum disorder and
intellectual disability among school-aged children
in North Carolina: Associations with race, rurality,
and resource availability. Autism Research. 2021;
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