Association between parental nativity and autism spectrum disorder among US-born non-Hispanic white and Hispanic children, 2007 National Survey of Children’s Health

Article Outline

• Abstract
• Methods
• Results
• Discussion
• References
• Copyright

Abstract 

Background

Limited studies suggest the prevalence of autism spectrum disorders (ASD) varies by whether maternal and child birth country are discordant.

Objective/Hypothesis

We explored associations between ASD and maternal and paternal nativity in a sample of US-born non-Hispanic white (NHW, n = 37,265) and US-born Hispanic (n = 4,690) children in the 2007 National Survey of Children’s Health (NSCH).

Methods

We assessed ASD prevalence within race-ethnicity and parental nativity subgroups. Prevalence ratios (aPR), comparing each group to NHW children with 2 US-born parents, were adjusted for child age, sex, and receipt of care in a medical home. Estimates were weighted to reflect US noninstitutionalized children. Standard errors were adjusted to account for the complex sample design.

Results

In NHW children with 2 US-born parents, ASD prevalence was 1.19%; estimates were similar for NHW children with a foreign-born mother or father. There was a striking heterogeneity between Hispanic children with 2 US-born versus 2 foreign-born parents (ASD prevalence 2.39% versus 0.31%, p = .05). Even after adjustment, PRs comparing ASD prevalence in Hispanic versus NHW children were vastly different for Hispanic subgroups, suggesting a substantially lower prevalence for Hispanic children with both parents foreign-born (aPR 0.2, 95% confidence interval 0.1-0.5) and a higher prevalence for Hispanic children with both parents US-born (aPR 2.0 [0.8-4.6]).

Conclusions

Previous studies comparing ASD prevalence between NHW and Hispanic children based on a composite Hispanic grouping without consideration of parental nativity likely missed important differences between these racial-ethnic groups. Continuing efforts toward improving early identification in Hispanic children are needed.

Keywords: Autistic disorder, Developmental disabilities, Prevalence, Population group, Race, Hispanic, Place of birth

Autism spectrum disorders (ASDs) are a group of neurodevelopmental disorders characterized by impairments in social interactions and communication and restricted, repetitive, and stereotyped patterns of behavior that typically emerge in the first few years of life [1]. Numerous genetic factors have been implicated in the etiology of ASDs and twin studies suggest that heritability might be greater than 90% [2], [3]; however, select prenatal environmental factors and adverse perinatal outcomes are also associated with ASDs, and the composite evidence supports the likelihood of gene-environment interactions [2]. Several sociodemographic factors, including maternal and paternal age, race, and socioeconomic status (SES), have also been associated with ASDs [4], [5], [6], [7], [8]. Because there is no biological test for ASDs and the diagnosis is based on in-depth behavioral observation, it is unclear whether these associations represent etiologic variation or differences in access to diagnostic services among families of affected children.

An emerging potential risk factor of interest is parental immigrant status. A small number of studies report associations between discordant maternal and child birth countries and autism. These include positive associations between maternal nativity outside Europe or North America and infantile autism in Swedish-born children [9], maternal foreign citizenship and autism in Danish-born children [10], [11], and maternal nativity outside Australia and ASD among children born in New South Wales [12]. Hypotheses advanced as potentially explaining these findings include lack of immunity to infectious agents more prevalent in the new country and the possibility that males with a genetic susceptibility for autism, who might themselves have social difficulties, might disproportionately marry foreign-born women because of more difficulty finding a partner in their home country [9], [10], [12].

In contrast to these positive associations, Croen et al found that maternal birth in Mexico was associated with a significantly lower prevalence of “full-spectrum-autism” in Californian-born children [13]. Cases of autism were identified from children served at a California regional developmental disabilities center. While there is no citizenship requirement for receipt of services, the authors posit that some mothers from Mexico might have been reluctant to seek care at this state-based center and that language and cultural differences might have impacted both care-seeking behavior and referrals from primary care providers. A subsequent analysis demonstrated that among children who were identified as having autism in the California services system, children of immigrant mothers had a later age at diagnosis [14].

The current literature on parental nativity and ASD is sparse. Moreover, 3 of the 5 studies were based on Scandinavian populations. The findings of an association between ASD and maternal immigrant status from these populations might not be generalizable to more culturally diverse populations, such as the United States. The sole assessment of parental nativity in a US population is based on 1989-1994 birth cohorts from a select segment of the United States and was limited to the most severe cases on the ASD spectrum. Further, a major limitation of most past studies is lack of data on father’s birth country. Only 1 study evaluated discordant paternal and child nativity and reported no association [10].

We explored associations between both parents’ nativities and prevalence of ASD among children in the 2007 National Survey of Children’s Health (NSCH). To our knowledge, this is the first study to examine this research question on a US-population–based sample of children covering all 50 states and the only US study to examine both maternal and paternal nativity together. The NSCH also covers a more recent range of birth cohorts than most past analyses, which is potentially important given the recent increase in the US prevalence of ASDs [4], [6].

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Methods 

The 2007 NSCH, a nationally representative random-digit-dial telephone survey, included households from all 50 states and the District of Columbia [15]. One child was randomly selected from households with children. The respondent was a knowledgeable parent or guardian. The weighted response rate was 51.2%, assuming that telephone numbers that rang with no answer or were busy on all call attempts were nonresidential. Interviews were conducted in English, Spanish, and 4 Asian languages.

We selected children who were born in the United States and aged 3-17 years at survey; we chose this age group because ASDs are often not diagnosed earlier. We further selected children residing with both biological parents at survey. In NSCH, parents’ nativities were only ascertained for parents residing with the child. Because the goal of this study was to examine nativities of both biological parents and whether these nativities were discordant with each other and the sample child, we excluded children in single-parent households and children residing with stepparents, adoptive parents, or in other family structures. We further restricted our sample to children who were not missing data on either ASD or maternal or paternal nativity. Percentage missing was <1% for each of these variables.

We examined parental nativity within subgroups based on child’s race-ethnicity because of unmeasured social/cultural factors potentially associated with both parental nativity and race-ethnicity. Here, we present findings for non-Hispanic white (NHW) and Hispanic children only. Other racial-ethnic groups had insufficient sample sizes of children with non-US parental nativities to estimate ASD prevalence.

The sample selection and general distribution of parental nativities is presented in Table 1. Altogether, our final sample included 37,265 and 4,690 NHW and Hispanic children, respectively; 6.7% of NHW children and 69.2% of Hispanic children had a foreign-born parent (either 1 or both). Parental nativity was ascertained by asking the parent respondent “Were you born in the United States?” and “Was [CHILD’S “OTHER PARENT”] born in the United States?” The vast majority of parent respondents were mothers (78%). Child race-ethnicity was ascertained from 2 questions on racial group and whether the child was of Hispanic or Latino origin. All children reported to be Hispanic were classified as Hispanic, regardless of racial group reported. Parents’ race-ethnicities were not ascertained.

Table 1. Sample selection within race-ethnicity subgroups

ASD was ascertained via 2 questions: “Were you ever told by a doctor or other health care provider that [CHILD] had autism, Asperger’s disorder, pervasive developmental disorder, or other autism spectrum disorder?” “Does [CHILD] currently have autism or ASD?” We defined a child as having an ASD if the parent responded affirmatively to both questions.

To determine whether any association with ASD was common to other behaviorally based disorders, we separately examined parent report that the child had an emotional, developmental, or behavioral problem other than ASD that was expected to last at least 1 year and necessitated treatment or counseling (non-ASD developmental problems). The survey did not include questions on every individual emotional, developmental, or behavioral condition; however, nearly 90% of the children classified as having non-ASD developmental problems were reported to have 1 of the following conditions with specific survey questions: attention-deficit/hyperactivity disorder, depression, anxiety, behavioral/conduct problems, and/or developmental delay affecting learning.

We assessed prevalence estimates of ASD and non-ASD developmental problems within race-ethnicity-parental nativity subgroups. Four categorizations were created. In each, NHW and Hispanic children were separately categorized; parental nativity was variously defined based on whether each parent was US- or foreign-born. The first categorization considered only maternal nativity in defining US- versus foreign-born and thus, categories were NHW-mother US-born, NHW-mother foreign-born, Hispanic-mother US-born, and Hispanic-mother foreign-born. The second and third categorizations were analogous to the first, except one considered only paternal nativity in defining foreign-born and one considered whether either parent was foreign-born. The fourth categorization was more comprehensive in that it considered all combinations of race-ethnicity, maternal nativity, and paternal nativity (8 levels in all).

Because the observed number of children in some subgroups was small, we calculated relative standard errors (RSE, standard error/prevalence estimate ×100) for each prevalence estimate and indicate those estimates that have a moderately high variability (30-50%) or a high variability (RSE 50-60%). We do not present estimates in which either the number of children with ASD or non-ASD developmental problems is ≤5 or the RSE is >60%.

In addition to assessing the general prevalence estimates for each of the above categories, we also computed adjusted prevalence ratios (aPR) and 95% confidence limits (CIs) from multivariable log-binomial regression models that included child age, sex, and whether the child received primary health care in a medical home as independent variables, in addition to race-ethnicity-parental nativity variables. We included child age to adjust for potential birth cohort effects in ASD diagnosis over time. We included child sex because of the high difference in prevalence between males and females previously reported [4], [5], [6]. Medical home was defined based on the American Academy of Pediatrics framework [16], which includes personal physician/nurse, usual place for care when sick, ability to obtain needed referrals, family centered care, and effective care coordination. Thus, this variable represents both access to and quality of primary health care. Past research indicates children with ASDs are less likely to receive care in a medical home than children without ASDs [4]. Additional sociodemographic factors, such as poverty status, were not included in the final models because of limited dispersion for some subgroups. We constructed four models, corresponding to the four categorization schemes for race-ethnicity-parental nativity. In all models, the referent category was NHW children with a US-born parent (either mother US-born, father US-born, or both parents US-born depending on the model). All prevalence and prevalence ratio estimates were weighted to reflect the population of US non-institutionalized children and to adjust for non-response. Standard errors were adjusted to account for the complex sample design using SUDAAN software.

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Results 

In NHW children with 2 US-born parents, ASD prevalence was 1.19% and similar estimates were observed for NHW children with either a foreign-born mother or foreign-born father (Table 2). Sample size constraints precluded assessment of NHW children with both parents foreign-born.

Table 2. Prevalence of autism spectrum disorder and other developmental problems by race-ethnicity and parental nativity among US-born non-Hispanic white and Hispanic children aged 3-17 years residing with both biological parents 2007, National Survey of Children’s Health^a

Child race-ethnicity and parental nativity	Autism Spectrum Disorders (ASD)			Non-ASD Developmental Problems
	%	aPRb	95% CI	%	aPRb	95% CI
Maternal Nativityc
NHWd, mother US-born	1.18	1.0	REF	3.25	1.0	REF
NHW, mother foreign-born	1.15f	0.8	0.4-1.9	2.39	0.7	0.3-1.2
Hispanic, mother US-born	1.81f	1.4	0.6-3.4	2.22	0.6	0.3-1.1
Hispanic, mother foreign-born	0.36f	0.2	0.1-0.5	1.79	0.4	0.2-0.9
Paternal Nativityc
NHW, father US-born	1.19	1.0	REF	3.27	1.0	REF
NHW, father foreign-born	0.75f	0.6	0.2-1.4	1.94	0.6	0.4-0.98
Hispanic, father US-born	1.96f	1.5	0.7-3.5	2.18	0.6	0.3-0.98
Hispanic, father foreign-born	0.26g	0.2	0.1-0.5	1.81	0.4	0.2-0.9
Both Parents’ Nativitiese
NHW, both parents US-born	1.19	1.0	REF	3.27	1.0	REF
NHW, either parent foreign-born	1.00	0.8	0.4-1.4	2.39	0.7	0.5-1.1
NHW, mother foreign-born-father US-born	1.40f	1.0	0.4-2.4	3.11	0.9	0.5-1.6
NHW, father foreign- born-mother US-born	0.81g	0.7	0.3-1.7	2.37	0.7	0.4-1.3
NHW, both parents foreign-born	-h	-	-	0.83g	0.2	0.1-0.7
Hispanic, both parents US-born	2.39f	2.0	0.8-4.6	1.82	0.5	0.3-0.8
Hispanic, either parent foreign-born	0.31f	0.2	0.1-0.4	2.02	0.5	0.2-0.9
Hispanic, mother foreign-born-father US-born	-	-	-	3.31g	0.7	0.2-3.0
Hispanic, father foreign-born-mother US-born	-	-	-	-	-	-
Hispanic, both parents foreign-born	0.31f	0.2	0.1-0.4	1.49f	0.3	0.1-0.8

In comparison to NHW children with 2 US-born parents, Hispanic children with either parent foreign-born or both parents foreign-born had a lower ASD prevalence (aPRs 0.2 for both). However, the “either” and “both” groups overlapped substantially. Assessments of specific subgroups of Hispanic children with 1 foreign-born and 1 US-born parent were limited by small sample sizes.

In contrast to the findings for Hispanic children with foreign-born parents, Hispanic children with 2 US-born parents had a higher ASD prevalence than NHW children (2.39% versus 1.19%) that approached but did not reach statistical significance (aPR 2.0 [0.8-4.6]). The prevalence heterogeneity between Hispanic children with 2 US-versus 2 foreign-born parents was even more striking (2.39% versus 0.31%, p = .05).

The prevalence of non-ASD developmental problems in US-born NHW children with both parents US-born was 3.27%. In comparison, several subgroups of children had significantly lower estimates including Hispanic children with 2 US-born parents, Hispanic children with 2 foreign-born parents, and NHW children with 2 foreign-born parents. Moreover, unlike the pattern of results observed for ASD, there was little variation in prevalence of non-ASD developmental problems for Hispanic children with 2 US-born versus 2 foreign-born parents.

Because sample sizes, particularly for some of the Hispanic subgroups, precluded us from developing models that included a fuller range of potential confounding factors, we descriptively assessed the demographic and health care profiles of children within each of the (mutually exclusive) race-ethnicity-parental nativity subgroups included in this analysis (Table 3). Child sex was comparable across all subgroups and child age was only moderately variable. NHW children in all parental nativity subgroups had generally similar profiles on most socioeconomic and health care characteristics examined. However, as expected, the percentage of NHW children with both parents foreign-born for which the primary household language was not English (33%) was much higher than for other NHW groups (1% or less). Additionally, parents of this group of children were slightly less likely to report receiving 2 key medical home components, effective care coordination and family centered care, than parents of other NHW children.

Table 3. Proportion of children with select demographic and health care characteristics by race-ethnicity and parental nativity^a

	NHW				Hispanic
	Both parents US-born	Mother only foreign-born	Father only foreign-born	Both parents foreign-born	Both parents US-born	Mother only foreign-born	Father only foreign-born	Both parents foreign-born
	(N = 34,996)	(N = 1,009)	(N = 906)	(N = 354)	(N = 1,880)	(N = 455)	(N = 504)	(N = 1,851)
Demographic characteristics
Age 12-17	39	36	31	26	32	32	44	33
Male	52	54	51	50	49	47	51	54
Highest education level >high school	83	87	90	89	76	60	54	24
Household income <200% federal poverty level	17	20	13	12	29	42	47	80
Someone in household employed at least 50 weeks of past year	96	95	98	95	95	86	91	78
Residence within a metropolitan statistical area	71	78	78	84	89	93	88	91
Primary language in home NOT English	0.3	1d	1e	33	2	35	20	85
Uninsured at survey or in last year	4	3d	5d	6d	6d	30d	6d	8
Health care characteristics
Usual place for care	98	97	97	94	95	94	88	85
Personal doctor/nurse	96	96	97	97	92	90	92	88
No problem getting referrals if needed	86	86	81	93	80	84	88	73
Care coordination when needed	76	81	78	69	73	71	58	64
Family centered careb	79	73	79	66	71	53	62	40
Care received in a medical homec	70	65	69	59	59	46	49	31

Hispanic children with both parents US-born were fairly comparable to NHW children with US-born parents, although they had a notably lower percentage of receipt of care in a medical home (59% versus 70%), and higher percentages of low household income (29% versus 17%) and primary household language not English (2% versus 0.3%). Hispanic children with 2 foreign-born parents were substantially less likely to come from households with higher parental education (24%) and more likely to come from low-income households (80%) than all other groups. They also had the lowest percentages of family centered care (40%) and care within a medical home (31%). Hispanic children with 1 foreign-born and 1 US-born parent had values that were roughly intermediate between those for Hispanic children with 2 US-born and 2 foreign-born parents. The proportion of children without health insurance at or just before the survey appeared to vary for some Hispanic subgroups; however, most estimates had large RSEs and thus should not be overinterpreted. Among Hispanic children with 2 foreign-born parents, primary household language was not English for 85% compared to 35%, 20%, and 33% for the Hispanic, mother only foreign-born, Hispanic, father only foreign-born, and NHW, both parents foreign-born subgroups, respectively.

Time between parents’ immigrations and child’s birth also varied by race-ethnicity. Among children with 2 foreign-born parents, the median times from maternal immigration to child birth were 9 and 5 years, for NHW and Hispanic children, respectively; the median times from paternal immigration to birth were 13 and 9 years. For both NHW and Hispanic children, both maternal and paternal immigration times were longer for those families in which only 1 parent was foreign-born (data not shown).

We further investigated sociodemographic characteristics of Hispanic children with 2 foreign-born parents, according to primary household language (Table 4). The families for which primary language was English had a higher SES than families for whom primary language was not English, as indicated by parental education and household income differences. However, the proportion of children receiving care in a medical home was low, regardless of primary language.

Table 4. Assessment of children with 2 foreign-born Hispanic parents by primary household language

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Discussion 

ASD prevalence among US-born Hispanic children varied by parental nativity. Compared with NHW children with US-born parents, ASD estimates were substantially lower in Hispanic children with 2 foreign-born parents and higher in Hispanic children with 2 US-born parents. The proportions of Hispanic children with 2 US-born parents or 2 foreign-born parents were both high 31% and 50%, respectively. In contrast, over 90% of NHW children had 2 US-born parents and there appeared to be less variation in ASD prevalence by parental nativity. Thus, in addition to demonstrating a marked heterogeneity of ASD prevalence within the subgroup of children classified as Hispanic, these findings further inform recent and future comparisons of ASD prevalence across racial-ethnic subgroups. Failure to consider the Hispanic prevalence heterogeneity might bias studies assessing differences between Hispanic and NHW children toward a null finding.

The lower ASD prevalence in Hispanic children with foreign-born parents is possibly explained by differences in parental awareness and access to care stemming from a lower level of acculturation for this subgroup. This is supported in that a similar association was observed between having foreign-born parents and non-ASD developmental problems. Nonetheless, for both ASD and non-ASD outcomes, the prevalence differential observed between Hispanic children with foreign-born parents and the referent group (NHW children with US-born parents) was not substantively changed after adjustment for medical home, a construct that includes not only access to care, but care deemed as sensitive to family values and customs and inclusive of effective care coordination and needed referrals. Even so, unmeasured confounding may remain. Since medical home components were parent-reported, we cannot rule out the possibility that responses were influenced by differing expectations of family centered care and care coordination among race-ethnicity and parental nativity subgroups.

Sample size constraints reduced our ability to fully assess other demographic factors. However, we note that Hispanic children with 2 foreign-born parents are distinctly different from all other subgroups on several factors related to SES, in addition to being less likely to receive care in a medical home. These findings were particularly pronounced in the 85% of this subgroup for whom English was not the primary household language. Thus, the concept of parental nativity is complex for Hispanic children, as it appears to encompass multiple underlying constructs related to language, SES, and quality of health-care. Previous research suggests that immigrant Latino parents are less likely to seek preventive care and mental health services and are more likely to rely on folk remedies than non-immigrant families even after controlling for SES [17], [18]. Language, lack of understanding of Latino culture by health care providers, and stigma associated with mental health conditions have been identified as key barriers to care-seeking.

Although our data on the sociodemographic profiles of study subgroups point generally toward SES and health care access differences as possibly explaining the low ASD prevalence among Hispanic children with immigrant parents, we cannot specifically explore this hypothesis in this cross-sectional study. Thus, alternative explanations, such as a “healthy immigrant effect” or increased resiliency among the children of foreign-born Hispanic parents, or differences across racial-ethnic-parental nativity subgroups in genetic or environmental risk factors for autism and other developmental conditions cannot be dismissed.

Several previous studies reported higher ASD estimates among children with foreign-born mothers [9], [10], [11], [12], and 1 study specifically reported an association with maternal-paternal birth country discordance [10]. We did not observe this association among the NHW children in our sample; in fact, the aPR for the association between ASD and having a foreign-born mother and US-born father was 1.0. The difference between this study and past studies might be explained by differences in the ethnicities of the foreign-born parents, and likewise, the degree of discordance on biological and cultural factors between the 2 parents. For example, in 1 study of Swedish-born children, maternal foreign-birth included only those mothers born outside Europe and North America [9]. In the current study, we lacked data on the birth countries of foreign-born parents; thus, we cannot discern the proportion of NHW children with foreign-born mothers from Canada versus Europe versus other countries. Additionally, in our sample, foreign-born mothers of NHW children had typically immigrated to the United States many years before the index child’s birth and thus might be more highly acclimated to their new country than foreign-born mothers in other studies.

We did not have sufficient sample to fully explore ASD prevalence in Hispanic children with discordant parental nativities. Our suggestive finding of a higher ASD prevalence among Hispanic children with 2 US-born parents is difficult to interpret. Because only the child’s race is collected in NSCH, we could not explore this association according to whether the parents’ race-ethnicities were discordant, which might be related to social and cultural differences between parents.

While the higher ASD prevalence among Hispanic children with US-born parents is most appropriately considered an exploratory finding, the composite pattern of results nonetheless indicate a large and significant differential in ASD prevalence within the Hispanic subgroup of children according to their parental nativity. Moreover, this variation appeared unique to ASDs, as it was not observed for non-ASD developmental problems. We lacked data to explore the reasons for these findings. ASD differs from other developmental problems in several respects. While many developmental disabilities might interfere with socialization, profound social deficits are a core, defining feature of ASDs. Moreover, given the likely strong genetic component [2], [3], ASD prevalence in various population subgroups might be positively or negatively impacted by factors related to the likelihood that a person with a genetic susceptibility for ASD will have children.

Although this study was limited by small sample sizes within some subgroups, it is the largest nationally representative sample available to assess this emerging area of research among US children. Even so, the prevalence rates presented here should be cautiously interpreted. We present these estimates to provide the reader with a general sense of the possible variation in diagnosed ASDs across race-ethnicity-parental nativity subgroups included in this analysis and for comparison to the ASD prevalence rate we previously reported for the general population of US children (1.1%) [4]. Also, even though several point estimates had large RSEs, we note that most of the relative comparisons were fairly stable.

Study limitations in addition to sample size constraints include lack of data on parental country of origin, parent specific race-ethnicities, and the specific primary household language if other than English. ASD and non-ASD developmental problems were parent-reported without clinical validation. However, previous studies suggest high reliability for parent-reported ASD [5] and comparability between ASD estimates from the NSCH and a US records-based surveillance system [6]. As mentioned, parent report might also be influenced by cultural differences between study groups which could lead to differences in interpretation of other questions, such as health care characteristics, that required some level of subjective response.

Our findings are not generalizable to all US children. We necessarily limited this sample to US-born children to test our hypothesis of interest. Because parental nativity was only ascertained for parents residing in the same household as the child, we also limited the sample to children living with both biological parents. Our final sample included 71% and 58% of the total US-born NHW and US-born Hispanic children, respectively, who were 3-17 years of age. While we cannot compare our final sample of children residing with both biological parents to other US data sources, we note that estimates of a slightly broader measure, the proportion of children residing with 2 parents (including step and adopted), were fairly comparable between the NSCH sample and households included in a recent US census survey (data not shown). (see US Census Bureau, Housing and Household Economic Statistics Division, Fertility & Family Statistics Branch. America’s Families and Living Arrangements: 2008. Available at: http://www.census.gov/population/www/socdemo/hh-fam/cps2008.html). The percentages of households with foreign-born parents were also comparable between the 2 data sources for both racial-ethnic groups.

Further, we conducted supplemental analyses of ASD prevalence according to maternal nativity for those children residing in single-mother households. Although sample sizes were small, we observed a similar prevalence differential in Hispanic children according to maternal nativity as that presented here for two-parent households (data not shown).

Recent reports suggest the marked prevalence gap between NHW and Hispanic children in the US that was reported from earlier studies [5], [6] has been reduced. Data from US population-based sites included in the Autism and Developmental Disabilities Monitoring (ADDM) network indicate that while ASD prevalence increased 55% between 2002 and 2006 for NHW children, it increased 91% for Hispanic children and thus, the NHW-Hispanic prevalence gap narrowed considerably [6]. Likewise, while the 2003 NSCH indicated that the ASD prevalence was significantly and markedly higher in NHW than Hispanic children, by 2007, the prevalence differential was much lower and no longer statistically significant [4], [5]. The findings of the current study provide a caution about simply concluding that access to care and use of ASD-related services might have equalized between NHW and Hispanic children and demonstrate the importance of assessing ASD in Hispanic children by parental nativity. Continued efforts are likely needed to increase early identification and treatments for Hispanic children with ASDs and other developmental problems. Even if the current immigration rate remains unchanged, the Hispanic population in the US is expected to continue to increase in the coming decades at a faster rate than that for other racial-ethnic groups (US Census Bureau, United States Population Projections: 200 to 2050, http://www.census.gov/population/www/projections/analytical-document09.pdf). Further in-depth study of this and other select US populations is needed.

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