Advisor(s)

Stacey Cofield

Committee Member(s)

Anastasia Hartzes
D Leann Long
Justin Leach
Sarah O'Kelley

Document Type

Dissertation

Date of Award

6-1-2026

Degree Name

Doctor of Public Health (DrPH)

School

School of Public Health

Department

Biostatistics

Abstract

Diagnosis of neurodevelopmental delays in children, including autism spectrum disorder, is an often lengthy and burdensome process, potentially placing children with economic instability at risk for diagnostic delay. The first aim of this dissertation was to explore the impact of economic stability on diagnostic timing of autism spectrum disorder via a scoping review of the literature. Papers were summarized by study design, data sourcing, handling of variables, statistical methodology, and the effect of economic stability factors on diagnostic timing of autism. Income and healthcare insurance were the most frequently employed measures of economic stability, with transportation, housing, and food security less frequently measured. Economic instability was associated with diagnostic delay in some papers, but this effect was inconsistent. In the context of these findings, opportunities for future research were explored. The second aim of this dissertation was to demonstrate effective survey design by outlining the development, implementation, and revision of an existing Social Determinants of Health (SDOH) survey within a tertiary interdisciplinary clinic. This paper summarized efforts to protect data integrity, handle missingness, improve language concordance, utilize exhaustive and mutually exclusive categories, clarify survey questions, and document follow-up care; this was accomplished through personnel training, adaptation of survey flow procedures, and revision of survey content. The third aim of this dissertation was to explore whether there were mean differences in child’s age by caregiver-reported economic concerns among children reporting to initial evaluation with a Developmental Behavioral Pediatrician. Among a sample of 776 surveys, 36% of caregivers reported at least one economic concern. Multivariable regression modeling yielded significant interactions between economic concerns and caregiver’s relationship to child, with older ages on average when the person reporting the economic concern was a caregiver other than the mother. The main effects models yielded evidence of a 3-4 month diagnostic delay among children with economic instability. This research highlights the diagnostic inequities perpetuated by economic instability and affords avenues within both clinical and public health spheres to mitigate barriers.

Keywords

autism;delay;economic;income;inequity;social determinants

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