A review of: Begeer, S., Bouk, S.E., Boussaid, W., Terwogt, M.M., Koot, H.M. (2008). Underdiagnosis and Referral Bias of Autism in Ethnic Minorities. Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-008-0611-5

The issue of under- or over-representation of a disorder within specific ethnic groups is a complicated one. There are specific disorders that are under-represented within a specific ethnic group because of some protective factor that makes such group less likely to acquire the disorder. For example, the rates of skin cancer in the African-American population are significantly lower than in the European-American population(although this has led to increase mortality rates among African Americans due to reduced screenings leading to late diagnosis). Yet, it is possible that some disorders are under-represented within an ethnic group simply because a systemic clinical bias in diagnosis and referrals. To examine this hypothesis, the authors of this study first examined 712 case records of children referred for ASD assessment in the Netherlands. They found that ethnic minority children (Turkish and Moroccan)were under-represented in this sample of referred kids as compared to Dutch children (2.1% vs. 4.4%). But does this represent a bias or is it simply that Turkish and Moroccan children are less likely to have ASD due to some protective factor? To answer this question, the authors sent 6 clinical vignettes to 82 pediatricians. The vignettes varied in their descriptions of various autism symptoms. Three ethnic background were represented, including 1) European minority (French or English) 2) Non-European minority (Moroccan and Turkish) and 3) Majority (Dutch). However, the ethnicity was independent of the clinical vignette, so that the vignette sent to one pediatrician could describe a Dutch child, while the SAME vignette sent to another pediatrician could describe a Turkish child. The authors found that vignettes describing Dutch (majority) children elicited significantly more references to autism than did vignettes describing European minority or non-European minority children. However, the mean rate of ASD based on an objective scale was equal across all three groups. This suggests that objective assessments may help minimize any potential clinical biases.


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One Response to Autism and ethnic minorities: possible referral bias?

  1. Autism Library says:

    Thank you very much for posting this. Equity issues in service delivery for autism is a major concern for me. I don’t have access to JADD and didn’t see this paper come through.

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