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Racial and Ethnic Group Differences in Service Utilization in Children with Autism Spectrum Disorder: The Role of Parental Stigma

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Title: Racial and Ethnic Group Differences in Service Utilization in Children with Autism Spectrum Disorder: The Role of Parental Stigma
Language: English
Authors: Karla Rivera-Figueroa, Stephanie Milan, Thyde Dumont-Mathieu, Diane Quinn, Inge-Marie Eigsti (ORCID 0000-0001-7898-1898)
Source: Autism: The International Journal of Research and Practice. 2025 29(5):1171-1183.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 13
Publication Date: 2025
Sponsoring Agency: National Institute of Mental Health (NIMH) (DHHS/NIH)
Contract Number: R01MH11268701A1
Document Type: Journal Articles
Reports - Research
Descriptors: Racial Differences, Ethnicity, Autism Spectrum Disorders, Parent Attitudes, Social Bias, Minority Groups, Access to Health Care, Socioeconomic Influences
DOI: 10.1177/13623613241298043
ISSN: 1362-3613
1461-7005
Abstract: Racial and ethnic disparities in service utilization in autism are widely documented. Autism-related parental stigma may play a role if parents from racial/ethnic minoritized backgrounds experience dual stigma from autism and from membership in a marginalized group. This study examines racial/ethnic differences in autism-related stigma and compares the impact of stigma on service utilization in a large, diverse sample of US-based parents of autistic children (final sample = 764; White 41.6%, Black 16.6%, Latino/a/x/Hispanic 20.9%, Asian 7.5%, Multiracial 9.6%, Native American 1.8%, Pacific Islander 0.5%, Middle Eastern 0.2%, and Other 0.2%). Parents completed online surveys assessing affiliate and community stigma, service utilization, and perceived unmet treatment needs. Small but significant racial/ethnic group differences emerged in some aspects of stigma and service utilization. Specifically, Asian and Latino/a/x parents were less likely to fully engage in recommended services; Asian parents endorsed less service availability; Latino/a/x and multiracial parents reported more unmet needs; and Asian and White parents reported significantly more affiliate stigma. There was little indication that stigma contributed to racial/ethnic differences in service utilization, except for Asian families. Results indicate that socioeconomic factors interact with race/ethnicity to impact service use and stigma.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1469228
Database: ERIC
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  Value: <anid>AN0184797741;f9d01may.25;2025Apr30.05:47;v2.2.500</anid> <title id="AN0184797741-1">Racial and ethnic group differences in service utilization in children with autism spectrum disorder: The role of parental stigma </title> <p>Racial and ethnic disparities in service utilization in autism are widely documented. Autism-related parental stigma may play a role if parents from racial/ethnic minoritized backgrounds experience dual stigma from autism and from membership in a marginalized group. This study examines racial/ethnic differences in autism-related stigma and compares the impact of stigma on service utilization in a large, diverse sample of US-based parents of autistic children (final sample = 764; White 41.6%, Black 16.6%, Latino/a/x/Hispanic 20.9%, Asian 7.5%, Multiracial 9.6%, Native American 1.8%, Pacific Islander 0.5%, Middle Eastern 0.2%, and Other 0.2%). Parents completed online surveys assessing affiliate and community stigma, service utilization, and perceived unmet treatment needs. Small but significant racial/ethnic group differences emerged in some aspects of stigma and service utilization. Specifically, Asian and Latino/a/x parents were less likely to fully engage in recommended services; Asian parents endorsed less service availability; Latino/a/x and multiracial parents reported more unmet needs; and Asian and White parents reported significantly more affiliate stigma. There was little indication that stigma contributed to racial/ethnic differences in service utilization, except for Asian families. Results indicate that socioeconomic factors interact with race/ethnicity to impact service use and stigma.</p> <p>Families of color often have less access to autism-related services and describe receiving lower-quality care than White families. The experience of being rejected and judged due to being a parent of an autistic child, called "stigma," might contribute to these healthcare inequalities. The purpose of this study was to test whether families from different racial/ethnic backgrounds differ in their use of autism services and experience of stigma and whether autism stigma leads to lower service engagement for families of color. Our results indicated that Asian parents were less likely to engage in recommended services fully, reported less service availability, and significantly higher levels of autism-related stigma. Furthermore, higher levels of stigma among Asian families partially contributed to lower service engagement. Similar to Asian parents, Latino/a/x parents were more likely to report lower service engagement; and Latino/a/x and Multiracial parents endorsed more unmet treatment needs than other groups. Interestingly, White parents reported levels of internalized stigma similar to those of Asian parents, and both groups reported experiencing more stigma compared to Latino/a/x, Black, and multiracial parents. Future research must examine the factors underlying these differences, and more attention should be directed to reducing stigma among Asian families to minimize its impact on service utilization.</p> <p>Keywords: access to services; affiliate stigma; Asian; barriers; Black; community stigma; discrimination; healthcare equity; Latino; multiracial; parental education; quality of services; socioeconomic status</p> <p>Racial and ethnic disparities in diagnosis, quality of care, and service utilization for autistic children have been widely documented (e.g. [<reflink idref="bib5" id="ref1">5</reflink>]; [<reflink idref="bib28" id="ref2">28</reflink>]). Recent studies suggest that autism-related family stigma may contribute to these disparities (e.g. [<reflink idref="bib41" id="ref3">41</reflink>]; [<reflink idref="bib43" id="ref4">43</reflink>]). However, research on autism-related stigma in the United States has primarily focused on White parents; studies done with communities of color are mostly qualitative and include small samples. This article aimed to quantify autism-related stigma among a diverse group of parents, compare the extent of stigma across racial/ethnic groups, and test whether autism-related stigma accounts for some of the racial/ethnic differences noted in the use of autism-related healthcare and intervention services.</p> <p>Stigma is the social process of labeling, stereotyping, and rejecting human differences ([<reflink idref="bib40" id="ref5">40</reflink>]). The experience of stigma negatively affects one's physical and mental health ([<reflink idref="bib36" id="ref6">36</reflink>]). The stigma literature distinguishes between two subtypes of stigmas: "public stigma" and "self-stigma." Public stigma is the negative attitudes of the general population toward a stigmatized individual, while self-stigma results from an individual's internalization of society's negative views ([<reflink idref="bib9" id="ref7">9</reflink>]). When family members experience self-stigma because of the stigmatized condition of a family member, it is termed "affiliate stigma" ([<reflink idref="bib31" id="ref8">31</reflink>]). Community stigma is the perception of public reactions and attitudes within one's community. This study focused on <emph>affiliate stigma</emph> and <emph>community stigma</emph>.</p> <p>Parents of autistic children frequently report experiencing stigma. Autistic children display socially atypical behaviors (e.g. spinning, hand flapping) and often struggle with emotion regulation, resulting in visibly disruptive tantrums and self-harming behaviors. In the absence of a physical indicator of disability, these behaviors leave caregivers susceptible to community judgment (e.g. [<reflink idref="bib13" id="ref9">13</reflink>]; [<reflink idref="bib15" id="ref10">15</reflink>], 1993, 2002). Autism-related stigma has been found to be associated with stress and adverse mental health outcomes for parents of autistic children (e.g. [<reflink idref="bib16" id="ref11">16</reflink>]; [<reflink idref="bib31" id="ref12">31</reflink>]). Although the role of autism-related stigma in healthcare utilization has not been studied, stigma contributes to reduced healthcare-seeking for other situations, such as child oppositional behavior (e.g. [<reflink idref="bib11" id="ref13">11</reflink>]). Parents may be less willing to engage in treatment when they fear being judged as a "bad parent." Consistent with this possibility, [<reflink idref="bib53" id="ref14">53</reflink>] found that increased perception of community stigma is associated with unmet treatment needs among families of autistic children. Stigma presents a barrier to seeking intervention.</p> <p>Although anyone may experience stigma, its manifestations are shaped by culture and context. Specific cultural values, social norms, beliefs/attitudes about mental illness, and discriminatory practices, among other factors, may all impact how stigma is expressed and experienced; however, the specific ways in which this happens continue to be understudied ([<reflink idref="bib1" id="ref15">1</reflink>]). Moreover, because various aspects of identity can lead to stigma, having more than one "stigmatized" condition is thought to increase the likelihood of negative outcomes, a so-called <emph>double disadvantage</emph> ([<reflink idref="bib12" id="ref16">12</reflink>]; [<reflink idref="bib24" id="ref17">24</reflink>]). Parents from racial and ethnic minoritized groups may experience more stigma, both from their child's autism-related behaviors and from being associated with a racially marginalized group. It is unknown how these dual factors impact the ability to obtain needed care for autistic children.</p> <p>Although limited and largely qualitative, there is some evidence that families of color whose children are autistic experience heightened levels of stigma. In a qualitative study, Latino/a/x mothers reported more guilt than their White counterparts when receiving an autism diagnosis ([<reflink idref="bib25" id="ref18">25</reflink>]). Another study found that immigrant parents (born outside the United States) and Latino/a/x parents with limited English proficiency experienced more stigma than non-Latino/a/x Whites and English-proficient Latino/a/x parents; the same was true for parents from other disadvantaged groups (e.g. lower parental educational attainment, poverty, and parental unemployment; [<reflink idref="bib53" id="ref19">53</reflink>]). A qualitative cross-cultural study reported that Latino/a/x and Black parents were more likely than Korean parents to have their parenting style questioned ([<reflink idref="bib46" id="ref20">46</reflink>]).</p> <p>Research among communities of color suggests that autism-related stigma influences healthcare engagement. Latino/a/x parents in the United States reported discomfort and fear of judgment in discussing their developmental concerns with community members and healthcare providers (e.g. [<reflink idref="bib3" id="ref21">3</reflink>]; [<reflink idref="bib54" id="ref22">54</reflink>]). Similarly, denial, shame, and stigma-related concerns contribute to delays in seeking healthcare for Black parents (e.g. [<reflink idref="bib10" id="ref23">10</reflink>]; [<reflink idref="bib46" id="ref24">46</reflink>]). However, a lack of representation of families of color in the autism-related stigma literature in the United States limits our assessment of cultural differences in the experience of autism-related stigma and its relationship with healthcare disparities. Understanding barriers to healthcare utilization among families of color is critical in reducing racial/ethnic health disparities and ensuring adequate access to care. To date, studies have been mostly qualitative and focused on select groups. Comparative, quantitative studies in large representative samples are needed to quantify the extent of these differences and their impact on access to care, treatment effectiveness, and, ultimately, long-term functional outcomes. In addition, quantitative studies allow for the systematic study of the factors underlying these disparities and their relative contribution, which may be helpful in the creation of primary preventive intervention programs, identifying at-risk families in clinical practice, and maximizing intervention effectiveness by targeting these factors specifically.</p> <p>The first aim of this preregistered study was to test for racial/ethnic group differences in a large, diverse sample of US-based families in autism-related service utilization and in autism-related affiliate and community stigma. The second goal was to test whether autism-related stigma served as a mediator between race/ethnicity and service utilization. We predicted that traditionally underserved groups (i.e. Black, Latino/a/x, Asian, and multiracial families[<reflink idref="bib4" id="ref25">4</reflink>]) would report significantly more stigma than White families, receive fewer autism-related services, have less availability for services, be less engaged in recommended services, and report more unmet treatment needs. We also predicted that stigma would be related to service utilization and would partially account for racial/ethnic differences in service utilization for White families versus families of color.</p> <hd id="AN0184797741-2">Methods</hd> <p></p> <hd id="AN0184797741-3">Study design</hd> <p>This preregistered study (https://doi.org/10.17605/OSF.IO/CU3PM) used a cross-sectional design. Data were collected in an online survey. Average completion time was 40 min; participants could complete multiple sessions within 2 weeks. The Institutional Review Board at the University of Connecticut approved the research protocol. There was no community involvement in the design of this study.</p> <hd id="AN0184797741-4">Participants</hd> <p>Participants were recruited through Simons Foundation Powering Autism Research Initiative (SPARK), a national research consortium of more than 100,000 individuals with autism and their family members ([<reflink idref="bib45" id="ref26">45</reflink>]). Participants were parents of a child formally diagnosed with autism, living in the mainland United States (1 of the 50 states), who were fluent in English and had access to a computer with Internet access. Inclusion criteria were (a) ages 18–80 years, (b) parent/guardian of a child with autism spectrum disorder (ASD) aged 6 years to 15 years, 11 months old, (c) able to provide information about the child's developmental history, and (d) score > 12 on the Social Communication Questionnaire (SCQ; [<reflink idref="bib42" id="ref27">42</reflink>]). If there were multiple autistic children in the family, parents were asked to report on the eldest to account for the impact of prior experiences with a child with ASD on service engagement. The age range for children was limited to 6–16 years to increase comparability of participants who were all in school, had completed the initial diagnosis process, and who had not yet begun the transition into adulthood, to minimize the impact of a recent diagnosis and the transition to adulthood on parental stigma.</p> <p>Recruitment used stratified convenience sampling based on parents' reported racial/ethnic identity to ensure representation of parents from diverse racial and ethnic backgrounds. Recruitment prioritized eligible participants who identified as a racial/ethnic minority; once these participants had been invited, slots were filled via recruitment of eligible non-Hispanic White participants. Participants received study reminders following the initial invitation. The number of participants invited per recruitment group was as follows: African American/Black only = 402, Native American only = 39, and Asian only = 195 regardless of Hispanic status; Latino/a/x of any race = 899; non-Hispanic African American/Black = 129, non-Hispanic Native American = 100, non-Hispanic Asian = 66, and non-White Other = 94 with racial overlap permitted; and non-Hispanic White only = 1555. The survey invitation had a response rate of 23%; the survey completion rate once registered was 92%. The SPARK sample comprises individuals who volunteered for research; the degree to which this sample is representative of the broader autism community has not yet been ascertained.</p> <p>A total of 826 participants consented to the study, and 764 participants completed the full survey. Because some participants exited the survey at different points without completing it, varying numbers of participants contributed data to each measure. The total number of participants who contributed to each analysis can be found in the result table for the analysis in question; see also Supplemental Table 1. This study did not impute missing data. There was no difference in demographic factors for participants with and without missing data. Participants with missing items on a particular measure were retained for analysis if fewer than 5% of items were incomplete.</p> <p>Self-reported race and ethnicity information was used to form groups. If the participant selected one racial category, they were assigned to that group; if participants selected multiple categories, assignment drew on responses to a follow-up question about their multiracial identity (e.g. Primarily Latino/a/x, Primarily White, Biracial/Multiracial generally, etc.). Participants selecting "Primarily Latino/a/x" were assigned to the Latino/a/x group; those selecting "multiracial /biracial/or both" were assigned to the multiracial group.</p> <p>For the 764 participants who finished the entire survey, groups were as follows: White (<emph>n</emph> = 322, 42.1%), Latino/a/x/Hispanic (<emph>n</emph> = 162, 21.2%%), Black American (<emph>n</emph> = 129, 16.9%), Multiracial (<emph>n</emph> = 73, 9.6%), Asian (<emph>n</emph> = 58, 7.6%), Native American (<emph>n</emph> = 12, 1.6%), Pacific Islander (<emph>n</emph> = 4, 0.5%), Middle Eastern (<emph>n</emph> = 2, 0.3%), and Other (<emph>n</emph> = 2, 0.3%); see Table 1 for full sociodemographic data. Native American, Middle Eastern, and Pacific Islander participants were excluded from group contrasts due to very small samples (e.g. fewer than 13 per group). The choice to keep groups such as Middle Eastern and Pacific Islanders separate from other groups was based on health disparity research, indicating that these socioculturally distinct groups are better examined separately ([<reflink idref="bib14" id="ref28">14</reflink>]; [<reflink idref="bib37" id="ref29">37</reflink>]). At the time of data collection, mean child age was 10 years (range: 6–16 years), and children were mostly male (77%). Most parents (87%) were between the ages of 30 and 49 years old, had an associate degree or higher (60%), and had "enough income to cover necessities" (81%).</p> <p>Table 1. Demographic information.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Entire sample</th><th align="left">White(<italic>n</italic> = 344)</th><th align="left">Black(<italic>n</italic> = 137)</th><th align="left">Latino/a/x(<italic>n</italic> = 173)</th><th align="left">Asian(<italic>n</italic> = 62)</th><th align="left">Multiracial(<italic>n</italic> = 79)</th></tr></thead><tbody><tr><td>Informant (%) (mother: father)</td><td>93:7</td><td>95:5</td><td>97:3</td><td>91:9</td><td>76:24</td><td>99:1</td></tr><tr><td>Parent age (years)</td><td>39.8 (6.4)</td><td>39.7 (6.2)</td><td>39.6 (6.8)</td><td>39.1 (6.4)</td><td>42.7 (6.1)</td><td>39.7 (6.4)</td></tr><tr><td>Child age (years)</td><td>10 (2.9)</td><td>10.9 (3.0)</td><td>9.9 (2.8)</td><td>10.2 (2.7)</td><td>9.6 (2.5)</td><td>10.4 (2.8)</td></tr><tr><td>Child sex (Male: Female)</td><td>633:167</td><td>265:69</td><td>110:25</td><td>128:43</td><td>53:8</td><td>59:17</td></tr><tr><td>Partnered: single (%)</td><td>71:29</td><td>75:25</td><td>50:47</td><td>78:22</td><td>87:13</td><td>67:33</td></tr><tr><td>⩽ High school (%)</td><td>13</td><td>15</td><td>10</td><td>16</td><td>0</td><td>14</td></tr><tr><td>Some college</td><td>26</td><td>25</td><td>30</td><td>28</td><td>3</td><td>33</td></tr><tr><td>Associate's degree</td><td>14</td><td>15</td><td>16</td><td>15</td><td>7</td><td>10</td></tr><tr><td>Bachelor's degree</td><td>23</td><td>25</td><td>20</td><td>23</td><td>36</td><td>13</td></tr><tr><td>Advanced degree</td><td>24</td><td>20</td><td>24</td><td>18</td><td>55</td><td>30</td></tr><tr><td colspan="7">Financial stability (%)</td></tr><tr><td> Occasionally/often unable to meet basic needs</td><td>18</td><td>18</td><td>24</td><td>17</td><td>5</td><td>29</td></tr><tr><td> Enough money for necessities</td><td>50</td><td>44</td><td>56</td><td>60</td><td>47</td><td>43</td></tr><tr><td> Enough money for some luxuries</td><td>31</td><td>38</td><td>18</td><td>24</td><td>48</td><td>28</td></tr><tr><td colspan="7">Income (%), US$</td></tr><tr><td> <15,999</td><td>12</td><td>10</td><td>20</td><td>11</td><td>2</td><td>17</td></tr><tr><td> 16,000–24,999</td><td>10</td><td>10</td><td>12</td><td>8</td><td>0</td><td>12</td></tr><tr><td> 25,000–34,999</td><td>10</td><td>6</td><td>12</td><td>16</td><td>6</td><td>9</td></tr><tr><td> 35,000–49,999</td><td>14</td><td>13</td><td>18</td><td>16</td><td>7</td><td>9</td></tr><tr><td> 50,000–74,999</td><td>17</td><td>16</td><td>17</td><td>16</td><td>16</td><td>21</td></tr><tr><td> 75,000–99,999</td><td>14</td><td>17</td><td>9</td><td>14</td><td>16</td><td>9</td></tr><tr><td> >100,000</td><td>25</td><td>28</td><td>12</td><td>20</td><td>53</td><td>22</td></tr><tr><td>No. of children in house</td><td>2.4 (1.2)</td><td>2.6 (1.2)</td><td>2.2 (1.2)</td><td>2.3 (1.1)</td><td>2.1 (1.1)</td><td>2.8 (1.5)</td></tr><tr><td>No. of autistic children</td><td>1.2 (0.53)</td><td>1.2 (0.53)</td><td>1.2 (0.53)</td><td>1.2 (0.45)</td><td>1.2 (0.43)</td><td>1.4 (0.65)</td></tr><tr><td>Insurance type (%) (public: private/both)</td><td>42:58</td><td>42:58</td><td>54:46</td><td>56:44</td><td>20:80</td><td>56:44</td></tr><tr><td>Place of birth (%) (inside: outside the US/ territories)</td><td>83:17</td><td>95:5</td><td>92:8</td><td>69:31</td><td>24:76</td><td>91:9</td></tr><tr><td>English as second language (%)</td><td>10</td><td>4</td><td>2</td><td>61<xref ref-type="table-fn" rid="tfn2">a</xref></td><td>75<xref ref-type="table-fn" rid="tfn3">b</xref></td><td>10</td></tr><tr><td colspan="7">Geographical area (%)</td></tr><tr><td> Rural</td><td>9</td><td>13</td><td>4</td><td>5</td><td>0</td><td>10</td></tr><tr><td> Small town</td><td>18</td><td>25</td><td>12</td><td>11</td><td>5</td><td>19</td></tr><tr><td> Suburb</td><td>57</td><td>54</td><td>55</td><td>63</td><td>71</td><td>50</td></tr><tr><td> Urban</td><td>17</td><td>8</td><td>27</td><td>21</td><td>25</td><td>21</td></tr><tr><td>Diagnosed after age 5 years (%)</td><td>25</td><td>34</td><td>17</td><td>16</td><td>8</td><td>28</td></tr><tr><td>SCQ total score<xref ref-type="table-fn" rid="tfn4">c</xref></td><td>23.2 (6.0)(13–38)</td><td>23.2 (6.1)(13–38)</td><td>22.7 (5.8)(13–34)</td><td>23.5 (5.8)(13–37)</td><td>23.8 (6.8)(13–37)</td><td>23.5 (5.4)(13–37)</td></tr></tbody></table> </ephtml> </p> <p>1 This table reports the descriptive statistics for all available demographic data, presented as Mean (Standard Deviation), percentage (%), count, and range (min–max). Sample size varies from 801 to 826 due to missing values. Native American, Middle Eastern, and Pacific Islander participants were included in the full sample but not enumerated categorically due to small participant numbers.</p> <ulist> <item>2 Latino/a/x language proficiency: some (5%), moderate (35%), and completely (60%).</item> <item>3 Asian language proficiency: some (2%), moderate (61%), and completely (37%).</item> <item>4 SCQ scores greater than 12 are considered to fall within the autism range for a young sample.</item> </ulist> <hd id="AN0184797741-5">Procedures</hd> <p>Eligible participants received an email invitation with a brief study description; eligibility was determined via responses to initial screening questions: (<reflink idref="bib1" id="ref30">1</reflink>) Are you able to provide information about [child's name]'s developmental milestones and autism diagnosis history? and (<reflink idref="bib2" id="ref31">2</reflink>) Are you currently living in the mainland United States (1 of the 50 states)? Following informed electronic consent, participants were presented with the survey; on completion, they received a US$25 gift card via email. Data collection took place from 1 September to 14 October 2021.</p> <hd id="AN0184797741-6">Measures</hd> <p>The survey included multiple measures, some of which were previously collected by SPARK.</p> <hd id="AN0184797741-7">Autism characteristics</hd> <p>Prior scores on the 40-item SCQ, Lifetime (SCQ; [<reflink idref="bib42" id="ref32">42</reflink>]) were used as a proxy for autism severity. This questionnaire is designed to identify the presence of challenges in social communication skills. The SCQ has good sensitivity and specificity: 93% and 58% for ages 2–6 years, 100% and 62% for ages 3–5 years. All children had an SCQ score of 13 or greater. Scores of 12 are a standard cut-off for research ([<reflink idref="bib33" id="ref33">33</reflink>]).</p> <hd id="AN0184797741-8">Sociodemographics</hd> <p>Age, education, financial status, race and ethnicity, geographic area, racial composition of the neighborhood, language proficiency and preference, country of origin, and time in the United States (for those born outside the United States) were collected using the University of Massachusetts Boston Comprehensive Demographic Questionnaire ([<reflink idref="bib47" id="ref34">47</reflink>]).</p> <hd id="AN0184797741-9">Affiliate stigma</hd> <p>The 22-item Affiliate Stigma Scale ([<reflink idref="bib30" id="ref35">30</reflink>]) provided a measure of affiliate stigma (e.g. stigma experienced by family members of an individual with a mental illness), using questions, such as "I feel inferior because one of my family members has a mental illness" and "Other people will discriminate against me if I am with my family member with a mental illness." Responses used a four-point Likert-type scale ranging from 1 (<emph>strongly agree</emph>) to 4 (<emph>strongly disagree</emph>). The measure has been used previously in studies of stigma in autism (e.g. [<reflink idref="bib26" id="ref36">26</reflink>]), replacing "mental illness" with autism, a change made in this study as well. Two items were omitted as irrelevant for parents of young children: "I avoid communicating with my child with autism" and "I have reduced my contact with my child with autism." The mean score served as the measure of <emph>affiliate stigma.</emph> The scale has excellent reliability, with Cronbach's alpha = 0.94.</p> <hd id="AN0184797741-10">Perceived stigma</hd> <p>The perception of public reactions and attitudes about autism in one's community was measured using the Parent-Reported Scale of Perceived Community Autism Stigma ([<reflink idref="bib53" id="ref37">53</reflink>]). However, 11 statements such as "People in my community think autism is a result of bad parenting or lack of discipline" and "People in my community are uncomfortable around my child with autism" were rated on a four-point Likert-type scale ranging from 1 (<emph>Definitely No</emph>) to 4 (<emph>Definitely Yes</emph>). Three items were excluded as recommended by [<reflink idref="bib53" id="ref38">53</reflink>] as they load onto a non-stigma factor: "People in my community... tell me that my child with autism will grow out of it," "...think that autism is a medical condition," and "...think children with autism have special abilities." The mean score across the remaining eight items served as a measure of <emph>perceived community stigma</emph>. The scale has excellent reliability (Cronbach's alpha = 0.83).</p> <hd id="AN0184797741-11">Service utilization</hd> <p>The Pathways to Treatment History Questionnaire ([<reflink idref="bib38" id="ref39">38</reflink>]) assessed autism service utilization and treatment history. Parents reported on first developmental concerns, diagnostic experiences, healthcare, educational service use, perceived unmet need, and insurance adequacy. They also reported whether their child had used any of 13 services: applied behavior analysis (ABA), sensory integration, occupational therapy, social skills training, speech language therapy, psychotherapy, early intervention, full-time special education, time in a resource room, paraprofessional or other academic supports, or school-based therapies. Usage was reported as "currently," 'in the past,' or "never." The number of services received (currently or in the past) was tallied as a measure of <emph>range of services received</emph>; responses ranged from 0 to 13.</p> <hd id="AN0184797741-12">Engagement in recommended services</hd> <p>Parents described their child's usage of those 13 healthcare and school services by answering the following question for each service: "Which best describes your use of (the service in question)?" Answer choices included the following: "This service was not recommended," and three levels of usage: "This service was recommended... (<reflink idref="bib1" id="ref40">1</reflink>) 'but my child did not receive it because it was unavailable', (<reflink idref="bib2" id="ref41">2</reflink>) 'but we chose not to receive it (e.g. did not like the service, felt it was unnecessary, etc.)', and (<reflink idref="bib3" id="ref42">3</reflink>) 'and my child received it partially/somewhat (e.g. not as fully as recommended)'." These levels were examined individually. Analyses used the following count variables: (a) number of services recommended, (b) number of services that were recommended but not available, (c) number of services that were recommended, but the family opted not to use, (d) number of recommended services that were used partially, and (e) number of underused services (those the family opted not to use or used partially; e.g. service underutilization). Ratio variables were created for descriptive purposes (number of services not used, used partially, or unavailable, as a proportion of services recommended).</p> <hd id="AN0184797741-13">Perceived unmet needs</hd> <p>Parents reported whether their child had received all treatments and services necessary to meet their developmental needs during the past 12 months, yielding a dichotomous Yes/No variable. This item served as a proxy for the subjective perception that treatments were inadequate to meet a child's needs, which is associated with community autism stigma ([<reflink idref="bib53" id="ref43">53</reflink>]).</p> <hd id="AN0184797741-14">Statistical analysis</hd> <p>Data were analyzed using SPSS<sups>®</sups> Statistics 28, along with the PROCESS v4.0 macro for SPSS ([<reflink idref="bib18" id="ref44">18</reflink>]). As a first step, we tested for racial and ethnic differences in sociodemographic factors and ASD symptom severity (child's age, number of autistic children in the household, ability to meet basic needs, income, parental education, and SCQ), which have been identified as possible confounds in research (e.g. [<reflink idref="bib23" id="ref45">23</reflink>]; [<reflink idref="bib50" id="ref46">50</reflink>]). Financial stability and parental education (which contribute to socioeconomic status, SES, and are also correlated with affiliate stigma in parents; [<reflink idref="bib7" id="ref47">7</reflink>]; [<reflink idref="bib35" id="ref48">35</reflink>]) were included to address the study aim of examining the unique contribution of racial/ethnic backgrounds independently from SES.</p> <p>To test for racial/ethnic differences in service utilization, generalized linear models (GLMs) with Poisson distributions probed for group differences in service utilization, controlling for confounding variables. This approach is flexible to overdispersion in distributions. Overall, model effects were tested via chi-square likelihood ratios, with Wald chi-squared tests for racial/ethnic group differences. When significant racial/ethnic group differences emerged, Fisher's least significant difference (LSD) pairwise comparisons were used to identify groups with differing service use. Binary logistic regression models, controlling for confounding variables, were used to capture group differences in unmet treatment needs. Multivariate Analysis of Covariance (MANCOVA) was used to test racial/ethnic group differences in affiliate stigma and perceived community stigma, controlling for the identified confounding variables. Post hoc Fisher's LSD pairwise comparison followed significant tests, as described above. We used Pearson correlations to examine the relationships among dimensions of stigma (affiliate stigma and perceived community stigma) and service utilization (services recommended, not available, partially used, and not used). For service outcomes with significant racial/ethnic group differences, simple mediation model analyses tested whether this difference was explained in part from stigma variables, using the PROCESS Model 4 ([<reflink idref="bib18" id="ref49">18</reflink>]) to estimate indirect effects and confidence intervals. The group showing differences in service use served as the reference.</p> <hd id="AN0184797741-15">Results</hd> <p></p> <hd id="AN0184797741-16">Demographic analyses</hd> <p>Racial groups did not differ in SCQ, <emph>F</emph>(<reflink idref="bib4" id="ref50">4</reflink>, 790) = 0.605, <emph>p</emph> = 0.66. Groups differed in parental education, <emph>F</emph>(<reflink idref="bib4" id="ref51">4</reflink>, 788) = 13.44, <emph>p</emph> < 0.001, financial stability, <emph>F</emph>(<reflink idref="bib4" id="ref52">4</reflink>, 788) = 7.21, <emph>p</emph> < 0.001, income, <emph>F</emph>(<reflink idref="bib4" id="ref53">4</reflink>, 754) = 13.35, <emph>p</emph> < 0.001, number of autistic children, <emph>F</emph>(<reflink idref="bib4" id="ref54">4</reflink>, 789) = 3.26, <emph>p</emph> = 0.012, and child's age, <emph>F</emph>(<reflink idref="bib4" id="ref55">4</reflink>, 781) = 4.91, <emph>p</emph> < 0.001. Specifically, Asian parents had a higher education level than all other groups; Black parents had significantly lower financial stability than White, Latino/a/x, and Asian parents; multiracial parents had more children with autism living in the household than all other groups; and White parents had older children than Black, Latino/a/x, and Asian parents. The following variables were considered to be confounding factors and thus were included as covariates in all multivariate statistical analyses: parental education, financial stability, number of autistic children in the household, and child age.</p> <hd id="AN0184797741-17">Racial/ethnic differences in service utilization</hd> <p>Healthcare providers recommended an average of 9.2 out of 13 clinical and school services (<emph>SD</emph> = 2.42; <emph>range</emph> = 0–13); families used 8.9 services (<emph>SD</emph> = 2.59, <emph>range</emph> = 0–13). Parents reported that, on average, 6% of recommended services were unavailable, 18% were partially used, and 2% were not used at all; see Table 2. Across the sample, 266 parents (34%) reported unmet treatment needs. The most frequently recommended services were speech and language therapy (90%), school-based therapy (90%), occupational therapy (89%), and ABA (80%); the services that were recommended least were sensory integration therapy (50%), counseling (50%), and physical therapy (46%). The overall model predicting range of services was not significant, <emph>Likelihood Ratio</emph> χ<sups>2</sups>(<reflink idref="bib8" id="ref56">8</reflink>) = 8.67, <emph>p</emph> = 0.37; see also Supplemental Table 2.</p> <p>Table 2. Service utilization by race/ethnicity.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Recommended services (range = 0–13)</th><th align="left">Services unavailable (range = 0–11)</th><th align="left">Services partially used (range = 0–13)</th><th align="left">Services not used (range = 0–8)</th></tr></thead><tbody><tr><td>Total sample (<italic>N</italic> = 756)</td><td>9.21 (2.42)</td><td>0.58 (1.20)</td><td>1.50 (1.91)</td><td>0.19 (0.61)</td></tr><tr><td>White (<italic>n</italic> = 327)</td><td>9.14 (2.47)</td><td>0.50 (0.99)</td><td>1.45 (1.84)</td><td>0.17 (0.62)</td></tr><tr><td>Black (<italic>n</italic> = 130)</td><td>9.34 (2.25)</td><td>0.70 (1.68)</td><td>1.35 (1.77)</td><td>0.21 (0.52)</td></tr><tr><td>Latino/a/x (<italic>n</italic> = 166)</td><td>9.32 (2.38)</td><td>0.51 (1.02)</td><td>1.70 (2.23)</td><td>0.11 (0.37)</td></tr><tr><td>Asian (<italic>n</italic> = 58)</td><td>9.36 (2.10)</td><td>0.69 (1.20)</td><td>1.90 (1.89)</td><td>0.29 (0.88)</td></tr><tr><td>Multiracial (<italic>n</italic> = 75)</td><td>8.92 (2.80)</td><td>0.81 (0.36)</td><td>1.28 (1.61)</td><td>0.29 (0.82)</td></tr><tr><td>Significant group differences <xref ref-type="table-fn" rid="tfn6">a</xref></td><td>None</td><td>Asian > White, Latino/a/x</td><td>Asian, Latino/a/x > White, Black, Multiracial</td><td>Asian, Multiracial > Latino/a/x</td></tr></tbody></table> </ephtml> </p> <ulist> <item>5 Results are presented as Unadjusted Mean (SD).</item> <item>6 Significant group differences were calculated for adjusted means, controlling for financial stability, parental education, child age, and number of autistic children.</item> </ulist> <p>The overall model predicting the number of recommended services was not significant, <emph>Likelihood Ratio</emph> χ<sups>2</sups>(<reflink idref="bib8" id="ref57">8</reflink>) = 3.90, <emph>p</emph> = 0.87. In contrast, the overall model predicting the number of unavailable services, <emph>Likelihood Ratio</emph> χ<sups>2</sups>(<reflink idref="bib8" id="ref58">8</reflink>) = 67.56, <emph>p</emph> < 0.001, was significant. Significant associations were observed between the number of unavailable services and financial stability, <emph>B</emph> = −0.22 <emph>(SE</emph><emph>=</emph>.059), <emph>p</emph> < 0.001; child age, <emph>B</emph> = −0.050 <emph>(SE</emph><emph>=</emph> 0.018), <emph>p</emph> = 0.004; and number of autistic children, <emph>B</emph><emph>=</emph> 0.33 <emph>(SE</emph> = 0.075), <emph>p</emph> < 0.001. Over and above these factors, racial/ethnic group was significantly associated, Wald χ<sups>2</sups>(<reflink idref="bib4" id="ref59">4</reflink>) = 9.96, <emph>p</emph> = 0.04. Post hoc comparisons (Fisher's LSD) of means adjusted for covariates indicated that Asian parents reported significantly more unavailable services (<emph>M</emph> = 0.76, <emph>SE</emph> = 0.13) compared to White (<emph>M</emph> = 0.49, <emph>SE</emph> = 0.04) and Latino/a/x (<emph>M</emph> = 0.48, <emph>SE</emph> = 0.05) parents; Black parents did not differ from other groups.</p> <p>The overall model predicting the number of recommended services that parents decided not to use was also significant, <emph>Likelihood Ratio</emph> χ<sups>2</sups>(<reflink idref="bib8" id="ref60">8</reflink>) = 26.73, <emph>p</emph> < 0.001. Only number of autistic children was a significant covariate in this model, <emph>B</emph> = 0.43 (<emph>SE</emph> = 0.13), <emph>p</emph> < 0.001. Race/ethnicity remained a significant factor after accounting for covariates, Wald χ<sups>2</sups>(<reflink idref="bib4" id="ref61">4</reflink>) = 10.11, <emph>p</emph> = 0.039. Post hoc comparisons (Fisher's LSD) indicated that Asian (<emph>M</emph> = 0.30, <emph>SE</emph> = 0.08) and multiracial parents (<emph>M</emph> = 0.23, <emph>SE</emph> = 0.06) opted out of services more often than Latino/a/x parents (<emph>M</emph> = 0.11, <emph>SE</emph> = 0.03); White and Black parents did not differ from other groups.</p> <p>A significant pattern emerged for partially used services, <emph>Likelihood Ratio</emph> χ<sups>2</sups>(<reflink idref="bib8" id="ref62">8</reflink>) = 37.15, <emph>p</emph> < 0.001; in this model, less financial stability was associated with more partially used services, <emph>B</emph> = −0.17 <emph>(SE</emph> = 0.038), <emph>p</emph> < 0.001. Race/ethnicity was associated with partially used services, controlling for covariates, Wald χ<sups>2</sups>(<reflink idref="bib4" id="ref63">4</reflink>) = 17.54, <emph>p</emph> = 0.002. Specifically, Asian (<emph>M</emph> = 1.96, <emph>SE</emph> = 0.19) and Latino/a/x parents (<emph>M</emph> = 1.70, <emph>SE</emph> = 0.10) endorsed significantly more partially used services than White (<emph>M</emph> = 1.45, <emph>SE</emph> = 0.07), Black (<emph>M</emph> = 1.30, <emph>SE</emph> = 0.10), and Multiracial parents (<emph>M</emph> = 1.24, <emph>SE</emph> = 0.13); see Table 3.</p> <p>Table 3. GLMs predicting service use from racial/ethnic group (N = 752).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left" colspan="4">Dependent variables:</th></tr><tr><th /><th align="left">Recommended services</th><th align="left">Services unavailable</th><th align="left">Services not used</th><th align="left">Services partially used</th></tr></thead><tbody><tr><td colspan="5">Covariates</td></tr><tr><td>Financial stability</td><td>1.23</td><td>14.33<xref ref-type="table-fn" rid="tfn9">***</xref></td><td>0.63</td><td>22.26<xref ref-type="table-fn" rid="tfn9">***</xref></td></tr><tr><td>Parental education</td><td>0.08</td><td>2.62</td><td>0.21</td><td>1.15</td></tr><tr><td>Child age</td><td>0.65</td><td>8.20<xref ref-type="table-fn" rid="tfn9">**</xref></td><td>1.93</td><td>0.43</td></tr><tr><td>Number of autistic children</td><td>0.03</td><td>19.07<xref ref-type="table-fn" rid="tfn9">***</xref></td><td>11.71<xref ref-type="table-fn" rid="tfn9">***</xref></td><td>0.43</td></tr><tr><td colspan="5">Independent variable</td></tr><tr><td>Race/ethnicity</td><td>1.78</td><td>11.36<xref ref-type="table-fn" rid="tfn9">*</xref></td><td>10.84<xref ref-type="table-fn" rid="tfn9">*</xref></td><td>18.71<xref ref-type="table-fn" rid="tfn9">***</xref></td></tr><tr><td>Omnibus test (Likelihood Ratio χ2, <italic>df</italic> = 8)</td><td>3.90</td><td>67.56<xref ref-type="table-fn" rid="tfn9">***</xref></td><td>26.73<xref ref-type="table-fn" rid="tfn9">***</xref></td><td>37.15<xref ref-type="table-fn" rid="tfn9">***</xref></td></tr><tr><td>Overall test result <xref ref-type="table-fn" rid="tfn8">a</xref> Wald χ2(4)</td><td>1.70</td><td>9.96<xref ref-type="table-fn" rid="tfn9">*</xref></td><td>10.11<xref ref-type="table-fn" rid="tfn9">*</xref></td><td>17.54<xref ref-type="table-fn" rid="tfn9">**</xref></td></tr></tbody></table> </ephtml> </p> <ulist> <item>7 The racial breakdown of the participants included in this analysis was White = 326; Black = 127; Latinx = 166; Asian = 58; Multiracial = 75. Data are presented as Wald χ<sups>2</sups> values (similar to <emph>F</emph> values in a MANCOVA).</item> <item>8 Tests effects of race/ethnicity based on linearly independent pairwise comparisons among estimated marginal means.</item> <item>9 <emph>p</emph> < 0.05, ** <emph>p</emph> < 0.01, *** <emph>p</emph> < 0.001.</item> </ulist> <p>Parents reported on whether their child received all the treatments and services necessary to meet developmental needs (yes/no response). Across the sample, 509 parents (66%) gave a yes response. "Yes" responses by group were White, 219 (68%); Black, 96 (74%); Latino/a/x, 99 (60%); Asian, 39 (67%); and Multiracial, 42 (56%). To test the impact of group on unmet treatment needs, we ran a binary logistic regression model. Results indicated significant racial/ethnic differences in unmet treatment needs, χ<sups>2</sups>(<reflink idref="bib8" id="ref64">8</reflink>) = 31.98, <emph>p</emph> < 0.001. Financial stability, <emph>B</emph> = −0.28 (<emph>SE</emph> = 0.10), <emph>p</emph> = 0.006, and parental education, <emph>B</emph> = 0.25 (<emph>SE</emph> = 0.059), <emph>p</emph> < 0.001, were significantly associated with perceived unmet needs, as was race/ethnicity, Wald χ<sups>2</sups>(<reflink idref="bib4" id="ref65">4</reflink>) = 11.87, <emph>p</emph> =.018, after controlling for covariates; see Table 4. Post hoc analyses indicated that multiracial and Latino/a/x parents had significantly more unmet needs than Asian, White, and Black parents.</p> <p>Table 4. Race/ethnicity as a predictor of unmet treatment needs: binary logistic regression (N = 749).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Variables</th><th align="left"><italic>B</italic> (<italic>SE</italic>)</th><th align="left"><italic>Exp</italic> (<italic>B</italic>) (95% CI)</th><th align="left">Block χ<sup>2</sup></th><th align="left">Nagelkerke <italic>R</italic><sup>2</sup></th></tr></thead><tbody><tr><td>Step 1: Covariates</td><td /><td /><td>19.86<xref ref-type="table-fn" rid="tfn11">***</xref></td><td>0.04</td></tr><tr><td>Financial stability</td><td>−0.28 (0.10)<xref ref-type="table-fn" rid="tfn11">**</xref></td><td>0.75 (0.61, 0.92)</td><td /><td /></tr><tr><td>Parental education</td><td>0.25 (0.06)<xref ref-type="table-fn" rid="tfn11">***</xref></td><td>1.3 (1.15, 1.44)</td><td /><td /></tr><tr><td>Child age</td><td>−0.00 (0.03)</td><td>1.0 (0.96, 1.05)</td><td /><td /></tr><tr><td>Number of autistic children</td><td>0.12 (0.15)</td><td>1.3 (0.84, 1.52)</td><td /><td /></tr><tr><td>Step 2: Race/ethnicity (dummy coded)</td><td /><td /><td>11.87<xref ref-type="table-fn" rid="tfn11">*</xref></td><td>0.06</td></tr><tr><td>White vs Black</td><td>−0.40 (0.24)</td><td /><td /><td /></tr><tr><td>White vs Latino/a/x</td><td>0.36 (0.20)</td><td /><td /><td /></tr><tr><td>White vs Asian</td><td>−0.23 (0.32)</td><td /><td /><td /></tr><tr><td>White vs Multiracial</td><td>0.42 (0.27)</td><td /><td /><td /></tr><tr><td>Overall model</td><td colspan="4">χ2(8) = 31.98<xref ref-type="table-fn" rid="tfn11">***</xref>, <italic>p</italic> < 0.001</td></tr></tbody></table> </ephtml> </p> <ulist> <item>10 The racial breakdown of the participants included in this analysis was White = 323; Black = 127; Latinx = 166; Asian = 58; and Multiracial = 75.</item> <item>11 <emph>p</emph> < 0.05, **<emph>p</emph> < 0.01, *** <emph>p</emph> < 0.001.</item> </ulist> <p>To summarize service utilization, Asian and Latino/a/x parents were less likely to fully engage in recommended services compared to Black, White, and Multiracial parents; Asian parents reported that services were less available than White and Latino/a/x parents; and multiracial and Latino/a/x parents reported more unmet needs than Asian, White, and Black parents, even after accounting for SES and child characteristics.</p> <hd id="AN0184797741-18">Racial/ethnic differences in stigma</hd> <p>Many participants who completed both stigma measures (<emph>n</emph> = 769) endorsed significant stigma (e.g. agree or strongly agree, or somewhat or definitely "yes" responses): 38.4% reported affiliate stigma (<emph>M</emph> = 1.83; <emph>SD</emph> = 0.60), and 57.9% reported community stigma (<emph>M</emph>= 2.27, <emph>SD</emph> = 0.65). The correlation between affiliate stigma and community stigma was significant, (<emph>r</emph>(<reflink idref="bib767" id="ref66">767</reflink>) = 0.45, <emph>p</emph> < 0.001. Univariate ANCOVAs indicated significant group differences in affiliate stigma, <emph>F</emph> (<reflink idref="bib4" id="ref67">4</reflink>, 735) = 3.81, <emph>p</emph> = 0.004. Asian (<emph>M</emph> = 1.98, <emph>SE</emph> = 0.08) and White parents (<emph>M</emph> = 1.89, <emph>SE</emph> = 0.03) endorsed significantly more affiliate stigma than Black (<emph>M</emph> = 1.75, <emph>SE</emph> = 0.05), Latino/a/x (<emph>M</emph> = 1.76, <emph>SE</emph> = 0.05), and Multiracial parents (<emph>M</emph> = 1.70, <emph>SE</emph> = 0.07). A MANCOVA analysis indicated significant effects of race/ethnicity on stigma, <emph>F</emph>(<reflink idref="bib8" id="ref68">8</reflink>, 735) = 2.50, <emph>p</emph> = 0.01, η<emph>p</emph><sups>2</sups> = 0.013, after controlling for covariates; see Table 5. Parental education and financial stability were significant covariates. Overall, Asian and White parents were more likely to internalize autism stigma than Black, Latino/a/x, and Multiracial parents.</p> <p>Table 5. Stigma as a function of race and ethnicity.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Affiliate stigma</th><th align="left">Community stigma</th></tr><tr><th align="left">Total sample(<italic>N</italic> = 744)</th><th align="left">1.83 (0.60)</th><th align="left">2.27 (0.65)</th></tr></thead><tbody><tr><td>White (<italic>n</italic> = 320)</td><td>1.87 (0.61)</td><td>2.30 (0.65)</td></tr><tr><td>Black (<italic>n</italic> = 127)</td><td>1.79 (0.60)</td><td>2.27 (0.67)</td></tr><tr><td>Latino/a/x (<italic>n</italic> = 164)</td><td>1.75 (0.56)</td><td>2.22 (0.61)</td></tr><tr><td>Asian (<italic>n</italic> = 58)</td><td>2.05 (0.60)</td><td>2.20 (0.65)</td></tr><tr><td>Multiracial (<italic>n</italic> = 75)</td><td>1.70 (0.59)</td><td>2.29 (0.70)</td></tr><tr><td>Significant group differences<xref ref-type="table-fn" rid="tfn13">a</xref></td><td>Asian, White > Black, Latino/a/x, Multiracial</td><td>None</td></tr></tbody></table> </ephtml> </p> <ulist> <item>12 Data are presented as unadjusted <emph>M</emph> (<emph>SD</emph>). Significant group differences are based on the adjusted means, controlling for financial stability, parental education, child age, and the number of children with autism.</item> <item>13 Significant group differences are based on adjusted means, controlling for financial stability, parental education, child age, and the number of children with autism.</item> </ulist> <hd id="AN0184797741-19">Stigma as a mediator between racial/ethnic group and service use</hd> <p>While associations between service use and stigma were significant, their magnitude was small (<emph>r</emph>'s = 0.08–0.19); see Table 6. There were few racial/ethnic group differences, limiting tests of mediating variables. Given racial/ethnic differences in affiliate stigma and service utilization, we conducted a mediation analysis using PROCESS to test for a significant indirect effect of racial/ethnic group on the reported number of underused services via stigma measures, comparing Latino/a/x and Asian parents (the only groups differing in utilization) to other groups; see Table 7. The <emph>number of underused services</emph> variable was used for this analysis. Total, direct, and indirect effects with 95% confidence intervals are shown in Table 8. Although mediation tests with cross-sectional data must be interpreted cautiously because of inflated estimates ([<reflink idref="bib34" id="ref69">34</reflink>]), results were significant and consistent with mediation. Specifically, affiliate stigma accounted for differences in utilization for Asian versus Black, Asian versus Latino/a/x, and Asian versus Multiracial groups. Affiliate stigma did not account for service utilization differences in Asian versus White families. There was no evidence of mediation in comparisons of Latino/a/x versus other groups.</p> <p>Table 6. Correlations between stigma and service utilization measures for the total sample (N = 769).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Service use</th><th align="left">Affiliate stigma</th><th align="left">Community stigma</th></tr></thead><tbody><tr><td>Recommended services</td><td>0.090<xref ref-type="table-fn" rid="tfn14">*</xref></td><td>0.04</td></tr><tr><td>Recommended services unavailable</td><td>0.099<xref ref-type="table-fn" rid="tfn14">**</xref></td><td>0.187<xref ref-type="table-fn" rid="tfn14">**</xref></td></tr><tr><td>Recommended services not used</td><td>0.00</td><td>−0.02</td></tr><tr><td>Recommended services partially used</td><td>0.103<xref ref-type="table-fn" rid="tfn14">**</xref></td><td>0.05</td></tr></tbody></table> </ephtml> </p> <p>14 <emph>p</emph> < 0.05, ** <emph>p</emph> < 0.01, *** <emph>p</emph> < 0.001.</p> <p>Table 7. Regression analysis predicting service underutilization from stigma and race/ethnicity.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Reference group = Asian (<italic>n</italic><italic>=</italic> 745)</th><th align="left">Reference group = Latino/a/x (<italic>n</italic><italic>=</italic> 745)</th></tr></thead><tbody><tr><td colspan="3">Predictors</td></tr><tr><td>Financial stability</td><td>−0.28 (0.10)<xref ref-type="table-fn" rid="tfn15">**</xref></td><td>−0.28 (0.10)<xref ref-type="table-fn" rid="tfn15">**</xref></td></tr><tr><td>Parental education</td><td>0.00 (−0.05)</td><td>0.00 (−0.05)</td></tr><tr><td>Child age</td><td>0.01 (0.03)</td><td>0.01 (0.03)</td></tr><tr><td>Number of children with autism</td><td>−0.00 (0.14)</td><td>−0.00 (0.14)</td></tr><tr><td>Affiliate stigma</td><td>0.34 (0.13)<xref ref-type="table-fn" rid="tfn15">**</xref></td><td>0.34 (0.13)<xref ref-type="table-fn" rid="tfn15">**</xref></td></tr><tr><td colspan="3">Race/ethnicity contrasts</td></tr><tr><td>Reference group vs White</td><td>−0.58 (0.29)<xref ref-type="table-fn" rid="tfn15">*</xref></td><td>−0.20 (0.19)</td></tr><tr><td>Reference group vs Black</td><td>−0.69 (0.33)<xref ref-type="table-fn" rid="tfn15">*</xref></td><td>−0.30 (0.238)</td></tr><tr><td>Reference group vs Multi</td><td>−0.65 (0.36)</td><td>−0.27 (0.28)</td></tr><tr><td>Asian vs Latino/a/x</td><td>−0.38 (0.31)</td><td /></tr><tr><td>Latino/a/x vs Asian</td><td /><td>0.38 (0.31)</td></tr><tr><td>Overall model</td><td><bold><italic>F</italic> (9, 735)</bold><bold>=</bold><bold>2.56, <italic>R</italic></bold>2 <bold>=</bold> 0.03<xref ref-type="table-fn" rid="tfn15">**</xref></td><td><bold><italic>F</italic> (9, 735)</bold><bold>=</bold><bold>2.56, <italic>R</italic></bold>2 <bold>=</bold> 0.03<xref ref-type="table-fn" rid="tfn15">**</xref></td></tr></tbody></table> </ephtml> </p> <p>15 Values in the table are Unstandardized Beta (<emph>SE</emph>). * <emph>p</emph> < 0.05, ** <emph>p</emph> < 0.01, *** <emph>p</emph> < 0.001.</p> <p>Table 8. Total, direct, and indirect effects in pathways from race to service utilization via affiliative stigma for Asian and Latino racial/ethnic group contrasts.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">Total effect (95% CI)</th><th align="left">Direct effect (95% CI)</th><th align="left">Indirect effect (95% CI)</th></tr></thead><tbody><tr><td>Asian vs White</td><td>−0.61* (−1.19, −0.04)</td><td>−0.58* (−1.16, −0.01)</td><td>−0.03 (−0.10, 0.00)</td></tr><tr><td>Asian vs Black</td><td>−0.76* (−1.40, −0.12)</td><td>−0.69* (−1.32, −0.05)</td><td>−0.08* (−0.18, −0.001)</td></tr><tr><td>Asian vs Latinx</td><td>−0.47 (−1.09, 0.16)</td><td>−0.38 (−1.00, 0.24)</td><td>−0.07* (−0.17, −0.001)</td></tr><tr><td>Asian vs Multi</td><td>−0.75* (−1.45, −0.04)</td><td>−0.65 (−1.36, 0.06)</td><td>−0.10* (−0.22, −0.01)</td></tr><tr><td>Latinx vs White</td><td>−0.16 (−0.53, 0.22)</td><td>−0.20 (−0.58, 0.18)</td><td>0.04 (0.00, 0.10)</td></tr><tr><td>Latinx vs Black</td><td>−0.31 (−0.77, 0.16)</td><td>−0.30 (−0.77, 0.16)</td><td>−0.01 (−0.05, 0.04)</td></tr><tr><td>Latinx vs Multi</td><td>−0.29 (−0.84, 0.26)</td><td>−0.26 (−0.81, 0.28)</td><td>−0.02 (−0.09, −0.03)</td></tr></tbody></table> </ephtml> </p> <hd id="AN0184797741-20">Discussion</hd> <p>This preregistered study aimed to quantify the impact of autism-related stigma on the use of autism-related services in a large, diverse, sample of US-based parents of autistic children. Identifying the factors that relate to successful engagement in relevant services is a priority for research and clinical practice; given documented racial and ethnic disparities in healthcare and intervention outcomes, group differences provide an evidence-based starting point.</p> <hd id="AN0184797741-21">Differences in service utilization</hd> <p>Contrary to hypotheses, there was limited evidence of racial/ethnic disparities in service utilization in our sample and little evidence of stigma contributing to service disparities. There was one exception: stigma was found to relate to service use for families identifying as Asian. Most children (82%) received community-based services. Parents in this study had relatively high levels of service involvement. While differences were small, Asian parents reported less access to recommended services and were more likely to use recommended services only partially. While the Asian community remains underrepresented in healthcare research, these results add to the small body of literature documenting autism-related healthcare disparities for Asian children compared to White children, including the reduced use of outpatient services ([<reflink idref="bib4" id="ref70">4</reflink>]) and lower diagnostic rates for Asian children with autism and intellectual disabilities ([<reflink idref="bib32" id="ref71">32</reflink>]). Latino/a/x parents also reported service underutilization, with reduced use of recommended services, consistent with documented disparities among Latino/a/x children ([<reflink idref="bib5" id="ref72">5</reflink>]; [<reflink idref="bib28" id="ref73">28</reflink>]). In addition, Latino/a/x parents reported choosing <emph>not</emph> to use recommended services less frequently than Asian and multiracial parents, suggesting that the underutilization of services may not be related to parental decision-making but rather to other pressures on access to services.</p> <p>Some 34% of the sample reported unmet service needs; multiracial and Latino/a/x parents endorsed significantly more unmet needs than White, Black, and Asian parents. Higher perceptions of unmet needs among multiracial and Latino/a/x parents, in the absence of differences in the number of recommended and received services, may reflect differences in treatment expectations. Latino/a/x parents commonly believe that autism is a temporary condition (e.g. [<reflink idref="bib41" id="ref74">41</reflink>]), which could lead them to believe that engagement in treatment should result in a complete resolution of symptoms, perceiving a greater need for treatment if these expectations are not met. Alternatively, parents may differ in their sense of parental efficacy in managing their child's symptoms and may therefore see more need for professional treatment. Disparities in the quality of care ([<reflink idref="bib27" id="ref75">27</reflink>]) could also lead parents to perceive treatments as insufficient. There may also be services that parents see as necessary that are not typically recommended (e.g. diets, pharmacological intervention); studies that examine engagement and the perceived effectiveness of services are needed to test for this possibility.</p> <p>English language proficiency may be a significant barrier for both Asian and Latino/a/x communities. In our sample, 75% of Asian parents, and 61% of Latino/a/x parents reported that English was not their first language. Although the vast majority of parents reported English proficiency, a large group (60% of Asians, and 35% of Latinos) endorsed "moderate" proficiency, suggesting that language barriers may be significant, especially for Asian families.</p> <p>Contrary to our predictions, Black parents did not report more service underutilization or unmet treatment needs after controlling for SES and child-related variables. However, Black and multiracial parents reported the highest unavailability of recommended services (when SES variables were not controlled for), suggesting that treatment disparities for Black and multiracial families may reflect broader socioeconomic inequalities. This result is consistent with research linking SES to healthcare and treatment services (see [<reflink idref="bib44" id="ref76">44</reflink>] for a review). For example, some services (e.g. one-to-one paraprofessional aides) may be more readily available in affluent schools; as noted above, Black parents had significantly less financial stability than other groups, which may have impacted their access to services. Future research should evaluate racial/ethnic healthcare disparities within their sociocultural context, as the factors underlying racial/ethnic healthcare disparities may differ across groups.</p> <hd id="AN0184797741-22">Differences in autism-related stigma</hd> <p>Contrary to hypotheses, families of color did not endorse more autism-related stigma than White parents. Rather, White and Asian parents were more likely to report internalized negative views about autism as compared to Black, Latino/a/x, and multiracial parents. Interestingly, Asian parents endorsed the highest levels of affiliate stigma (when not controlling for sociodemographic factors), making this an essential consideration for clinical work with these families. Immigration status and language fluency may be related to these findings, as the Asian parents in our study were predominately non-US-born. Immigration may impact stigma experiences ([<reflink idref="bib21" id="ref77">21</reflink>]; [<reflink idref="bib39" id="ref78">39</reflink>]; [<reflink idref="bib53" id="ref79">53</reflink>]), perhaps due to national differences in autism awareness ([<reflink idref="bib51" id="ref80">51</reflink>]), acculturation, and discrimination. Asian caregivers in the United States often report reluctance to share the diagnosis with their support network ([<reflink idref="bib17" id="ref81">17</reflink>]), unsatisfactory relationships with healthcare providers ([<reflink idref="bib6" id="ref82">6</reflink>]; [<reflink idref="bib22" id="ref83">22</reflink>]; [<reflink idref="bib46" id="ref84">46</reflink>]), and perceptions of embarrassment in extended family members ([<reflink idref="bib8" id="ref85">8</reflink>]). Reduced social support can also increase the negative effects of stigma, including via interactions with these experiences ([<reflink idref="bib20" id="ref86">20</reflink>]; [<reflink idref="bib31" id="ref87">31</reflink>]).</p> <p>Cultural differences likely influence stigma. Studies with Asian parents of autistic children report that parents tend to value and emphasize academic achievement, self-motivation, and management skills ([<reflink idref="bib19" id="ref88">19</reflink>]; [<reflink idref="bib49" id="ref89">49</reflink>]; [<reflink idref="bib48" id="ref90">48</reflink>]), which may lead to greater affiliate stigma if a child does not meet expectations in these domains. The Asian parents in the current study were generally highly educated, and parental educational attainment was related to higher stigma levels, supporting the relevance of this cultural difference. The tendency to value one's social image and social worth based on performance and interpersonal roles, known as <emph>saving face</emph> ([<reflink idref="bib29" id="ref91">29</reflink>]), could also heighten affiliate stigma. For instance, parents of children with Intellectual Disability who are more concerned with saving face tend to report more affiliate stigma and greater psychological distress ([<reflink idref="bib29" id="ref92">29</reflink>]). Although cultural factors alone are unlikely to fully explain these differences, the results of this study suggest that there are sociocultural factors beyond SES that may impact how families experience autism stigma. The role of culture in stigma is likely complex and influenced by sociodemographic factors, such as financial situation and parental education, both of which were significantly associated with stigma in this study. Of course, race and ethnicity are only proxies for other systemic factors, which must be considered in studies of stigma.</p> <hd id="AN0184797741-23">Stigma's association with service utilization and availability</hd> <p>Consistent with hypotheses, autism-related stigma was associated with parent-reported service utilization, although the relationship was small across groups. Both dimensions of autism stigma were related to service availability; community stigma was the most strongly associated. Reduced availability of services and more significant community stigma may be a function of living in a community with fewer resources ([<reflink idref="bib53" id="ref93">53</reflink>]) and to reduced access to knowledge about autism. Interestingly, affiliate stigma was the only stigma dimension associated with the partial use of services, suggesting that the internalization of negative views, not merely the perception of those views, ultimately leads to service underutilization. Parents with higher levels of affiliate stigma might be less likely to follow through on recommendations or engage in services out of fear of feeling blamed or judged. Thus, clinical interventions that focus on reducing internalized stigma among parents may be an effective way to increase service engagement; psychoeducational interventions about stigma, cognitive behavioral interventions targeted at modifying self-stigmatizing beliefs, and interventions that include peer support and group formats may serve to reduce internalized stigma (see review by [<reflink idref="bib2" id="ref94">2</reflink>]). Increasing community knowledge and awareness of autism is also likely to be helpful.</p> <p>A primary goal of this study was to determine whether stigma accounted for racial/ethnic differences in service utilization. Given the unexpectedly small racial/ethnic group differences in service utilization, our ability to test this was limited. Results suggested that while affiliate stigma partially accounted for Asian families using fewer services than Black and multiracial parents, it did not account for their lower service use compared to White parents. Stigma did not account for differences in service utilization among Latino/a/x parents. These findings suggest that differences in affiliate stigma are not the <emph>primary</emph> factor driving autism healthcare disparities in families of color, with the possible exception of Asian families.</p> <hd id="AN0184797741-24">Representativeness in autism research</hd> <p>Parents in this study were recruited via a large research database; their involvement in this database makes them more informed about autism and potentially better connected to services. In our sample, 82% of children received community-based services, compared to 62%–72% in a national study of 1420 children with autism, aged 6–17 years ([<reflink idref="bib52" id="ref95">52</reflink>]). Parents in this sample were also relatively financially stable and educated, although there was variability in SES across groups. These factors may have contributed to reduced racial/ethnic differences in service and service engagement, and decreased the role of stigma in service engagement. Autism-related affiliate stigma likely plays a more significant role in creating and maintaining racial/ethnic disparities among families that are not yet engaged in treatment, are generally less connected to services, and who have other risk factors, such as limited English proficiency or recent immigrant status. Although families of color in this sample may be better resourced than similar populations outside of SPARK, racial/ethnic differences in service engagement and stigma levels were still observed and disproportionally impacted minoritized groups, which speaks to the pervasiveness of racial/ethnic healthcare disparities in this country. However, this study indicates that group differences tend to be small when families of color have resources and information. Whether being involved in a community that provides better access to information and resources serves as a protective factor is an important question for future research. Ideally, future research will test links between stigma and racial/ethnic healthcare disparities <emph>before</emph> parents connect to services and will include more socioeconomically and linguistically marginalized families.</p> <hd id="AN0184797741-25">Limitations</hd> <p>This study recruited a large and diverse sample of families with autistic children from across the United States. Findings are limited in several dimensions. First, the families in these studies were generally well resourced and already connected to services, as stated above, which may limit the generalizability of findings. Second, intergroup variability was not fully captured in this study. Although there are shared cultural and experiential factors, groups such as "Asian" and "Latino/a/x" combine parents of different nationalities and acculturation statuses. For instance, parents from Mexico versus Puerto Rico likely have different experiences (e.g. those related to immigration). In this study, most parents were acculturated to mainstream American culture, and although there were several parents for whom English was a second language, inclusion criteria for SPARK required English proficiency; thus, the current findings may not generalize to recent immigrants and those with more limited English proficiency. Third, the cross-sectional nature of this study limits our ability to make causal assumptions.</p> <p>Despite these limitations, this study included one of the largest and most diverse samples of autism-related stigma to date, providing insight into the experiences of families often underrepresented in autism research. Most of these families reported relatively limited autism-related stigma and a high level of service engagement. However, several racial/ethnic group differences emerged, highlighting the importance of studying how race and ethnicity independent of SES shape the experience of raising a child with autism. In an increasingly diverse society, researchers and practitioners must understand the impact of the cultural context on children and families. This awareness could enhance culturally informed practices and decrease existing racial and ethnic autism-related healthcare disparities.</p> <hd id="AN0184797741-26">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-aut-10.1177_13623613241298043 for Racial and ethnic group differences in service utilization in children with autism spectrum disorder: The role of parental stigma by Karla Rivera-Figueroa, Stephanie Milan, Thyde Dumont-Mathieu, Diane Quinn and Inge-Marie Eigsti in Autism</p> <p>The authors thank the Simons Foundation Powering Autism Research Initiative (SPARK) for making this research possible by providing access to their database and aiding in recruitment and data collection.</p> <ref id="AN0184797741-27"> <title> References </title> <blist> <bibl id="bib1" idref="ref15" type="bt">1</bibl> <bibtext> Abdullah T., Brown T. L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review. 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E., Sinche B., Mejia A., Cobian M., Becker T., Nicolaidis C. (2014). Latino parents' perspectives on barriers to autism diagnosis. Academic Pediatrics, 14(3), 301–308.</bibtext> </blist> </ref> <ref id="AN0184797741-28"> <title> Footnotes </title> <blist> <bibtext> The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by a University of Connecticut Provost's Tier I Research Award and by NIMH R01MH112687-01A1 to Inge-Marie Eigsti.</bibtext> </blist> <blist> <bibtext> Inge-Marie Eigsti</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0001-7898-1898</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> <blist> <bibtext> The labels used for racial and ethnic groups within the United States are fraught with limitations. We have chosen the labels currently used in many academic settings, with recognition that each of these categories includes participants from varied backgrounds and that the terms used for research on race and ethnicity do not fully align with the terms commonly used by individuals in those groups.</bibtext> </blist> </ref> <aug> <p>By Karla Rivera-Figueroa; Stephanie Milan; Thyde Dumont-Mathieu; Diane Quinn and Inge-Marie Eigsti</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib28" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib41" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib43" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib40" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib36" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib31" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib13" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib15" firstref="ref10"></nolink> <nolink nlid="nl9" bibid="bib16" firstref="ref11"></nolink> <nolink nlid="nl10" bibid="bib11" firstref="ref13"></nolink> <nolink nlid="nl11" bibid="bib53" firstref="ref14"></nolink> <nolink nlid="nl12" bibid="bib12" firstref="ref16"></nolink> <nolink nlid="nl13" bibid="bib24" firstref="ref17"></nolink> <nolink nlid="nl14" bibid="bib25" firstref="ref18"></nolink> <nolink nlid="nl15" bibid="bib46" firstref="ref20"></nolink> <nolink nlid="nl16" bibid="bib54" firstref="ref22"></nolink> <nolink nlid="nl17" bibid="bib10" firstref="ref23"></nolink> <nolink nlid="nl18" bibid="bib45" firstref="ref26"></nolink> <nolink nlid="nl19" bibid="bib42" firstref="ref27"></nolink> <nolink nlid="nl20" bibid="bib14" firstref="ref28"></nolink> <nolink nlid="nl21" bibid="bib37" firstref="ref29"></nolink> <nolink nlid="nl22" bibid="bib33" firstref="ref33"></nolink> <nolink nlid="nl23" bibid="bib47" firstref="ref34"></nolink> <nolink nlid="nl24" bibid="bib30" firstref="ref35"></nolink> <nolink nlid="nl25" bibid="bib26" firstref="ref36"></nolink> <nolink nlid="nl26" bibid="bib38" firstref="ref39"></nolink> <nolink nlid="nl27" bibid="bib18" firstref="ref44"></nolink> <nolink nlid="nl28" bibid="bib23" firstref="ref45"></nolink> <nolink nlid="nl29" bibid="bib50" firstref="ref46"></nolink> <nolink nlid="nl30" bibid="bib35" firstref="ref48"></nolink> <nolink nlid="nl31" bibid="bib767" firstref="ref66"></nolink> <nolink nlid="nl32" bibid="bib34" firstref="ref69"></nolink> <nolink nlid="nl33" bibid="bib32" firstref="ref71"></nolink> <nolink nlid="nl34" bibid="bib27" firstref="ref75"></nolink> <nolink nlid="nl35" bibid="bib44" firstref="ref76"></nolink> <nolink nlid="nl36" bibid="bib21" firstref="ref77"></nolink> <nolink nlid="nl37" bibid="bib39" firstref="ref78"></nolink> <nolink nlid="nl38" bibid="bib51" firstref="ref80"></nolink> <nolink nlid="nl39" bibid="bib17" firstref="ref81"></nolink> <nolink nlid="nl40" bibid="bib22" firstref="ref83"></nolink> <nolink nlid="nl41" bibid="bib20" firstref="ref86"></nolink> <nolink nlid="nl42" bibid="bib19" firstref="ref88"></nolink> <nolink nlid="nl43" bibid="bib49" firstref="ref89"></nolink> <nolink nlid="nl44" bibid="bib48" firstref="ref90"></nolink> <nolink nlid="nl45" bibid="bib29" firstref="ref91"></nolink> <nolink nlid="nl46" bibid="bib52" firstref="ref95"></nolink>
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  Label: Title
  Group: Ti
  Data: Racial and Ethnic Group Differences in Service Utilization in Children with Autism Spectrum Disorder: The Role of Parental Stigma
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  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Karla+Rivera-Figueroa%22">Karla Rivera-Figueroa</searchLink><br /><searchLink fieldCode="AR" term="%22Stephanie+Milan%22">Stephanie Milan</searchLink><br /><searchLink fieldCode="AR" term="%22Thyde+Dumont-Mathieu%22">Thyde Dumont-Mathieu</searchLink><br /><searchLink fieldCode="AR" term="%22Diane+Quinn%22">Diane Quinn</searchLink><br /><searchLink fieldCode="AR" term="%22Inge-Marie+Eigsti%22">Inge-Marie Eigsti</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-7898-1898">0000-0001-7898-1898</externalLink>)
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  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Autism%3A+The+International+Journal+of+Research+and+Practice%22"><i>Autism: The International Journal of Research and Practice</i></searchLink>. 2025 29(5):1171-1183.
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  Label: Availability
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  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 13
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
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  Label: Sponsoring Agency
  Group: SrcSuprt
  Data: National Institute of Mental Health (NIMH) (DHHS/NIH)
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  Label: Contract Number
  Group: NumCntrct
  Data: R01MH11268701A1
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Racial+Differences%22">Racial Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Ethnicity%22">Ethnicity</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Attitudes%22">Parent Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Social+Bias%22">Social Bias</searchLink><br /><searchLink fieldCode="DE" term="%22Minority+Groups%22">Minority Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Health+Care%22">Access to Health Care</searchLink><br /><searchLink fieldCode="DE" term="%22Socioeconomic+Influences%22">Socioeconomic Influences</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/13623613241298043
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1362-3613<br />1461-7005
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Racial and ethnic disparities in service utilization in autism are widely documented. Autism-related parental stigma may play a role if parents from racial/ethnic minoritized backgrounds experience dual stigma from autism and from membership in a marginalized group. This study examines racial/ethnic differences in autism-related stigma and compares the impact of stigma on service utilization in a large, diverse sample of US-based parents of autistic children (final sample = 764; White 41.6%, Black 16.6%, Latino/a/x/Hispanic 20.9%, Asian 7.5%, Multiracial 9.6%, Native American 1.8%, Pacific Islander 0.5%, Middle Eastern 0.2%, and Other 0.2%). Parents completed online surveys assessing affiliate and community stigma, service utilization, and perceived unmet treatment needs. Small but significant racial/ethnic group differences emerged in some aspects of stigma and service utilization. Specifically, Asian and Latino/a/x parents were less likely to fully engage in recommended services; Asian parents endorsed less service availability; Latino/a/x and multiracial parents reported more unmet needs; and Asian and White parents reported significantly more affiliate stigma. There was little indication that stigma contributed to racial/ethnic differences in service utilization, except for Asian families. Results indicate that socioeconomic factors interact with race/ethnicity to impact service use and stigma.
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  Data: 2025
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  Data: EJ1469228
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1469228
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        Value: 10.1177/13623613241298043
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 13
        StartPage: 1171
    Subjects:
      – SubjectFull: Racial Differences
        Type: general
      – SubjectFull: Ethnicity
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Parent Attitudes
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      – SubjectFull: Social Bias
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      – SubjectFull: Minority Groups
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      – SubjectFull: Access to Health Care
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      – SubjectFull: Socioeconomic Influences
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      – TitleFull: Racial and Ethnic Group Differences in Service Utilization in Children with Autism Spectrum Disorder: The Role of Parental Stigma
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            NameFull: Thyde Dumont-Mathieu
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            – TitleFull: Autism: The International Journal of Research and Practice
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