Why Autism in Black Boys Is Often Missed

Despite the increasing awareness and understanding of ASD, "African-American and Latino children with autism are diagnosed at older ages than white children, giving them less of an opportunity for proper intervention and treatment." Mandell et al. (2002) found that "African-American children with autism were diagnosed an average of 1.4 years later than white children and spent eight more months in mental health treatment before being diagnosed." In this study, Black children were 2.6 times less likely to receive an autism diagnosis than white children.

Black boys are typically first diagnosed with other conditions, such as attention-deficit/hyperactivity disorder (ADHD). Black children, particularly boys, are more likely to be misdiagnosed with behavioral disorders like ADHD or conduct disorders before receiving an autism diagnosis.

However to diagnose ADHD, another mental disorder should not better explain the symptoms, and since social communication and social interaction deficits can be observed for both autism and ADHD, how are Black boys being left behind for autism? Understanding why ASD is frequently missed in Black boys is crucial for addressing these disparities, ensuring equitable access to care, and obtaining early interventions.

1. Lack of Psychological Testing and Assessment

Relying solely on pediatricians and possibly starting medication aimed at correcting problematic behaviors will generally not help with diagnosing ASD. Medication may be able to help treat certain symptoms or co-occurring challenges, such as anxiety, but it will not help with the core challenges of ASD.

When medication fails, some parents will then seek psychological testing. Unfortunately, by then, many of these boys are older, and early childhood interventions for ASD can no longer be implemented. Many Black boys grow up without adequate behavioral interventions and services which is concerning given that early intervention in early childhood before school entry has been found to improve receptive and expressive language, cognitive functioning, and adaptive skills.

2. Schools

Students can meet the eligibility requirements for ASD in some states, which are mandated by their State Board of Education. However, many Black boys are not receiving educational testing and assessment in schools for their symptoms of ASD. This is challenging for parents since schools typically want to manage behaviors. As a result, their children's Individualized Education Plans (IEPs) are written based on behaviors that may not include goals that assist these boys with ASD. In schools serving predominantly Black communities, there is a greater emphasis on managing behavior rather than understanding the underlying causes. This can lead to an over-reliance on disciplinary measures rather than diagnostic evaluations.

3. Systemic Bias and Stereotyping in Healthcare

In my clinical experience, systemic bias and stereotyping in healthcare play a significant role in the underdiagnosis or misdiagnosis of autism in Black boys. These biases, often unconscious, affect how healthcare professionals interpret and respond to behaviors exhibited by Black boys, leading to disparities in diagnosis and care that can affect their assessment and interpretation of behaviors in Black boys.

For instance, behaviors that might be recognized as signs of autism in white children can be misinterpreted in Black boys. Behaviors such as poor eye contact, repetitive actions, or difficulty in social interactions—typical signs of autism—are sometimes viewed through the lens of negative racial stereotypes. Instead of recognizing these as potential symptoms of autism, they may be labeled as "defiance," "disobedience," or signs of conduct disorders. Black boys are more likely to be labeled as aggressive or hyperactive, resulting in a focus on behavioral correction instead of developmental support, delaying an accurate autism diagnosis and appropriate interventions.

4. Cultural Differences in Behavior and Communication

The healthcare system is often not equipped to recognize how autism may manifest differently across racial and cultural groups. For example, nonverbal communication or social behaviors that might be seen as typical within a Black family or community may not be raised by the family in consultation with providers. As a result, the signs of autism may not be properly recognized or assessed.

Differences in communication styles, both verbal and non-verbal, may also contribute to the under-recognition of autism in Black boys. For example, eye contact and conversational patterns that are seen as atypical in some cultures might be more normative in others.

There may be less awareness of the signs of autism among Black families due to a lack of information and resources. Without adequate knowledge, parents might not recognize the early signs of autism or know when to seek help. Black parents might face additional challenges in advocating for their children’s needs in educational and healthcare settings, particularly if they encounter bias or systemic racism.

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5. Underrepresentation in Research

Much of the autism research has historically focused on white populations, leading to diagnostic criteria and screening tools that may not adequately account for variations in how autism presents in children from different racial or ethnic backgrounds. Just as disparities exist in medical care and diagnosis for minority children with autism (Thomas et al. 2007), current autism research is not adequately representative of the African American segment of the U.S. population.

Since autism research has focused predominantly on white, middle-class children, it leads to a skewed understanding of how autism manifests. Diagnostic criteria and behavioral expectations are often based on these populations, overlooking cultural differences that may affect how autism presents in Black boys. Underrepresentation in research exacerbates the biases healthcare providers may have when diagnosing Black boys.

Conclusion

The underdiagnosis of ASD in Black boys is a complex issue. By improving early detection and intervention, we can work towards ensuring that non-white children, specifically Black boys, receive a diagnosis of ASD when appropriate, and obtain the support and care they need.