A STAT First Opinion essay argues the delay in this community is not about language, insurance, or geography — it is stigma, a culturally enforced code of family honor that recasts a neurodevelopmental condition as a moral event, and that pediatricians, schools, and community…
The federal autism prevalence number has been climbing for a decade, and the latest tally, 1 in 31 US children, has become a familiar headline in pediatric waiting rooms. Inside many South Asian American households, the same number is a different kind of data point: a diagnosis that a family agrees, often without ever saying so, to keep quiet.
A June 15 STAT First Opinion essay by Dr. Ritu Goel, a double board-certified child, adolescent, and adult psychiatrist, argues that the silence is not the product of language barriers, insurance gaps, or distance from a specialist. It is the product of stigma, a culturally reinforced code of family honor that recasts a neurodevelopmental condition as a moral event.
Goel names that code with two words her community uses, and that a wider American audience usually does not. Izzat, broadly translatable as family honor or family standing, is treated as something an autistic child can damage by existing in public. The diagnosis threatens the household's reputation with the extended family, with neighbors, with the aunties at the temple or the mosque. Karma, in the everyday sense most American readers know it, is a generic idea of cosmic give-and-take. In Goel's account of how stigma operates in many South Asian American homes, karma carries a sharper freight: the framing that disability is the visible record of a past wrongdoing, a debt that has to be paid in this life. The bill, in this reading, is the child's. The guilt, Goel writes, is the mother's.
The clinical cost of that arrangement is measurable in time. Children from racial and ethnic minority groups are diagnosed with autism roughly a year to a year and a half later than their white peers. The standard explanation in pediatric and public-health writing is structural: language, insurance, geography. Goel's argument is that for many South Asian American families, those are not the binding constraints. The binding constraint is what the family is willing to admit inside its own walls.
The fix, on the terms the essay sets, is not a generic appeal to families to talk more openly about disability. That framing inverts the diagnosis, suggesting the problem is in the parents' willingness to be honest, and leaves the surrounding institutions untouched. The change has to come from the institutions a family already encounters: the pediatrician's office, the public school, the community organization, the state Medicaid program.
In the clinic, the doorway is the question a pediatrician asks. A checklist of developmental milestones, ticked off in front of both parents, can produce a false negative: the father nods, the mother stays quiet, the visit ends. A second, private conversation with the caregiver who is most often the first to notice the regression, usually the mother, is a different instrument. The 18-month and 24-month autism screens that the American Academy of Pediatrics already recommends become useful only when the room is set up to hear the answer.
In the school, the doorway is who gets referred, and how fast. Developmental preschool evaluations under the Individuals with Disabilities Education Act carry a 60-day timeline; the delay in many districts is longer, and the families least likely to push are the families that most need a case manager willing to push on their behalf.
In the community, the doorway is a name the family already trusts. South Asian American mental-health and autism organizations, including the South Asian Mental Health Initiative and Network (SAMHIN) and AASHA for Autism, have spent the last decade building exactly the kind of first-call referral line that a pediatrician, an imam, or a worried grandfather can hand a family without asking the family to publicly identify as the parent of an autistic child. Those organizations, and the clinicians who work with them, are the practical unit of change. They are also the unit the essay asks the health system to fund, refer into, and treat as a covered partner rather than an outside advocacy group.
The 1-in-31 figure will keep rising, because the diagnostic criteria have widened and the screening has improved. The figure that is not in any CDC release is the undercount: the children in South Asian American homes who meet the criteria and are not counted because no one in the family has yet said the word out loud to a clinician. The gap between those two numbers is the population the essay is asking the health system to take responsibility for.