Autism spectrum disorder (ASD) is characterized by deficits in social communication and repetitive or restrictive behavior patterns that lead to impairments in functioning.1 Families of children with ASD are more likely to report financial problems and to need additional income for their child’s medical care compared to families of children with non-ASD developmental disabilities, mental health conditions, or both.2, 3 Outcomes are especially poor among low-income ASD households, with over three-fourths reporting at least one material hardship in 2017.4 Recent estimates indicate that one in 36 American children meet case criteria for ASD5 and over half (56%) of children with ASD live in low-income households.4 However, we know few details about the economic conditions and use of financial supports among low-income households of children with ASD.

The growing commitment to create social and physical environments that promote health has led to widespread recognition of the importance of social determinants of health (SDoH).6, 7 Social determinants are the “conditions in the environments in which people are born, live, learn, work, play, worship, and age.”8 Material hardship - or the deprivation of basic needs such as food, housing, and health9 - is a known social determinant that leads to challenges in accessing healthcare and further exacerbates other determinants.10, 11 The large population of low-income children with ASD, coupled with poor health outcomes and high levels of material hardship, underscores the importance of policies and practices that mitigate the adverse effects of poverty for this subpopulation.

Federal safety net programs – such as the Supplemental Security Income (SSI) program and the Supplemental Nutrition Assistance Program (SNAP) - may help to alleviate the adverse effects of poverty among children with ASD and their families. For instance, SSI and SNAP participation has been shown to significantly reduce the odds of poverty, hardships, and food insecurity among broader samples of children.12, 13 A review of empirical evidence also found that safety net participation positively impacts health outcomes and reduces health-related spending.14 Since the 2000s, ASD caseloads have increased dramatically across a wide range of safety net programs;15, 16, 17 however, the extent of use is still far less than what is expected given population estimates of low-income children with ASD.15 Underutilization of public benefits among eligible households is a concern for policymakers, as it reduces the probability that safety net programs will achieve their goal to reduce poverty and its associated consequences. The field would benefit from in-depth information on the population of recipients themselves and what leads to program use.

This paper examined the distribution, parameters, and determinants of safety net program use among a nationally representative sample of children, ages 3-17 years, from low-income households (under 200% FPL). We addressed the following two aims: 1) to compare the material hardships and use of safety net programs (cash assistance and SNAP) among low-income children with ASD relative to those of low-income children with and without other SHCN, and 2) to identify predictors of safety net program use and non-use among all low-income children. Given the high rates of medical expenditures documented in studies of children with ASD,18 we hypothesized that material hardships would be more common among children with ASD than children with other SHCN (who also experience complex health needs and health-related consequences) and particularly worse than children with neither ASD nor SHCN. We also anticipated that public health insurance coverage will have a positive relationship to safety net program use among low-income households of children. This was based on the significant overlap between Medicaid coverage and safety net program enrollment observed among broader populations.19

At present, the development of policies that facilitate safety net program access among households of children with ASD are impeded by three critical gaps in research. First, the existing evidence base on safety net program access is largely based on studies that focus on broad, heterogeneous samples of children with disabilities, with many studies focusing on a wide range of mental health disorders. It is unclear if the findings presented in the literature translate to the subpopulation of children with ASD. Second, the bulk of research is primarily descriptive and does not include a comparison group of non-users. Consequently, much of our understanding captures the experiences of only a portion of the households that safety net policies are designed to serve. Finally, many studies aggregate safety net programs into one group. Although a growing body of research has focused on the use of SNAP among the subgroup of children with autism,20, 21, 22 there has been comparatively much less research on other programs such as cash assistance. Our study extends the current literature by disaggregating our sample according to ASD status, including a comparison group of children who do not receive benefits, and focusing on both cash assistance and SNAP as programs of interest.