Science at the heart of medicine

How Biochemical and Socioeconomic Factors Account for the Low Prevalence of Autism

Spectrum Disorders in LatinosBy : Denise Dailey &

Kimberley Seoane

Background

• Rates of ASD diagnoses have increased from 1:150 to 1:88

• However, prevalence remains at 8 per 1000 cases in Hispanics compared to 12 per 1000 in Non-Hispanic Whites

Source: CDC

Objectives

• To understand the different types of Autism Spectrum Disorders• To research the potential causes of ASDs• To research the observed genetic and biological expressions of ASDs• To assess possible disparities that contribute to low ASD prevalence in

Hispanic households.

• To analyze the socioeconomic factors that may cause these disparities

What is ASD?

• Developmental impairments in social interactions

• Subtypes of ASD:> Asperger’s syndrome> Autism> Pervasive Developmental

Disorder

Some Causes of ASDs

• Chemicals used as drugs

• Normal and Abnormal Genetic Mutations

• Chemicals found in the environment

Drugs associated with increased risk of autism: Thalidomide

• Ingestion of thalidomide

http://newsimg.bbc.co.uk

Thalidomide

• A study of 100 Swedish thalidomide embryopathy cases found a strong association between gestational use of thalidomide and the development of typical autism

• Binds to the Cereblon protein

• Inherited mutations in this protein have been shown to lead to learning and memory deficits

• Early embryonic exposure to thalidomide in rodents has caused behavioral abnormalities that mimic the hallmarks of autism.

Other drugs associated with increased risk of autism:

Misoprostol

Valoproic acid

Cocaine

Ethanol

Environmental Exposure to Chemicals

• Children’s Environmental Health Center - “Exploring the Environmental Causes of Autism and Learning Disabilities.”

• Lead• Methylmercury

• PCBs• Organophosphate Pesticides• Organochlorine Pesticides• Endocrine Disruptors• Automotive Exhaust

• Polycyclic Aromatic Hydrocarbons• Brominated Flame Retardants• Perfluorinated Compounds• First hand smoking

Genetic Studies:

• Twin Studies:> Identical 35-90%> Fraternal 0-30%

• Effect of Maternal Age

Source: CDC

Normal and Abnormal Genetic Mutations

Anatomical Expression of Gene Mutations

Expression of Gene Mutations in Brain Chemistry

• Children with ASD demonstrated decreased gray matter concentrations of Choline, creatine and phosphocreatine, N-acetylaspartate (NAA) and Myo-inositol (ml) compared with children with TD.

• Gray matter Choline transverse relaxation was also prolonged for the ASD sample compared with the TD group.

• The children with ASD demonstrated significantly decreased levels of Choline and mI and trend-level NAA in gray matter compared with the DD group.

• For white matter, both children with ASD and children with DD showed a similar pattern of NAA and mI level decreases.

• In several analyses, cerebral volume contributed significantly as a covariate.

Disparities in Healthcare in Autism Diagnosisin Hispanic Communities

1. Socio-Economic Differences

A) Race Disparities

B) Economic Disparities

C) Maternal Education

D) Culture

2. Language Barriers

A) Ability to understand advice

B) Foreign vs. U.S. born parents

3. Difficulties in screening ASDs

20%

Socioeconomic Components

35% 36%

14%

Kaiser State Health Facts

36%

14%

30%

26%

Krauss, N.A., Weinick, R.M. (2000). Racial/ethnic differences in children's access to care. American Journal of Public Health, Vol. 90(11). 1771-1774.

Disparities in Healthcare Services

White HispanicDifficulties in Obtaining Phone Advice 1 2.4    Problem Getting Care from Specialist 1 3.8    No Preventative Care 1 5.3    Timely Delivery of Acute Care 1 18.6

Not Poor Near Poor Poor1 2.1 2.7     1 2.5 3.3     1 1.1 1.7     1 2.4 4.8

Race Disparities Economic Disparities

For every 100,000 Hispanics, there are 29 Hispanic Health Professionals

Socio-Economic Differences

Cultural Component

• Bilingual Household

• U.S. born parents vs. foreign parents

Schieve, L.A. et al. (2012). Association between Parental Nativity & ASD Among US-born Non-Hispanic White & Hispanic Children, 2007 National Survey of Children’s Health. Disability and Health Journal, Vol. 5(1).

% with ASD

Hispanic, both parents US born(n = 1,880)

2.4

Hispanic, both parents foreign born(n = 1,851)

0.3

Difficulties in Screening ASDs

• Subjective nature of screening

• Concerns with diagnosis of children in developmental stage

• History with misdiagnosis of ASD as other disorders

Apparent Healthcare Disparities:Results

• Primary Outcome:> Multiple disparities seem to contribute to lower ASD prevalence

rate in Hispanic• Secondary Outcome:

> Slow rates of ASD Screening> Low number of Successful Referrals> Limited Access to Primary Healthcare> Effects of Cultural components> Socioeconomic Status> All of which intensify genetic and environmental effects

associated with autism

Conclusion

Cultural and socio-economic components such as limited access to health care and language barriers, exacerbate the effect of chemical and genetic implications of ASD in Hispanic children. This results in difficulties in diagnosing ASD from an early stage, ultimately leading to the perception of low prevalence of ASD in Hispanics.

Limitations of the study

• Unavailability of local statistics

• Unequal representation within sample populations

Future Directions

How Should the Problem be Addressed?•Multicultural considerations

- Interpreters- Family practices/backgrounds- Screening with cultural competency

•In-clinic referrals to specialist

•Advocate for fewer cuts in Medicaid/SCHIP

•Awareness

Acknowledgements

Mentors: Roberto Lleras

Elvira Longordo Ph. D.

Einstein Staff

•Lizandra Jimenez

•Nora Esteban, MD

•Ms. Hope M Spano

•The Library Staff

•Hal Strelnick, MD

•Gabriel Cruciani

• Maria Gomez, MD• Maria Santos, MD• Assumpta Madu, MD• Ronald Walsh, MD• Albert Einstein College

of Medicine• Hispanic Center of

Excellence