ADHD

Ethnic Disparities in ADHD Diagnosis

CHALANDA JONES, MD

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in African American children at two-thirds the rate of that in white children, despite that African American children display greater ADHD symptomatology. ADHD also is reportedly underdiagnosed in Hispanic children compared with white children.

In their recent article, Morgan et al1 hypothesized that this disparity in ADHD diagnosis and treatment is a result of racial/ethnic minority children’s less-frequent access to health professionals, less utilization of health care services, less-frequent questioning by health professionals about developmental concerns, a lower likelihood of referral by school professionals, a limited ability to pay for health care, and stigma in some racial/ethnic subcultures attached to the identification and treatment of disability. The authors’ objective was to examine the dynamics of racial/ethnic disparities in diagnosis from kindergarten to 8th grade and disparities in treatment in 5th and 8th grade.

The study analyzed data from the Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999 (ECLS-K), a national database of descriptive information about the cognitive, social, emotional, and physical development of a representative cohort of U.S. children. The data were collected from the children, their families, and their schools in spring 1999, fall 1999, spring 2000, spring 2002, spring 2004, and spring 2007.

The authors’ study group comprised the children in the ECLS-K cohort who had received a diagnosis of ADHD. The study group included an equal proportion of boys and girls; 19% were Hispanic, 16% were non-Hispanic African American, 57% were non-Hispanic white, and 8% were of other races/ethnicities. Data were collected about mothers’ age at a child’s birth; whether the child had low birth weight; and whether the child had health insurance. Also recorded were parents’ education level, occupation, and income level, and whether the interview had been conducted in English.

Kindergarten through 5th grade teachers used psychometrically validated behavioral scales to rate the frequency of the children’s externalizing and learning-related behaviors; acting-out behavior such as fighting, acting impulsively, and disrupting the classroom; and learning-related behavior such as attention, organization, and ability to work independently. Children’s academic achievement was estimated using the average scores of reading and math tests taken during each survey wave. Whether the children’s took any prescription ADHD medication also was noted.

The authors used discrete-time logit models to identify factors predictive of the timing of an ADHD diagnosis from kindergarten to 8th grade, in contrast to those of previous studies, which predicted an ADHD diagnosis at a given point in time. In addition, the authors used logistic regression modeling to estimate racial/ethnic disparities in ADHD medication use.

African American children, Hispanic children, and children of other minority races/ethnicities were 69% less likely to receive an ADHD diagnosis than were white children. Boys were more likely than girls to get a diagnosis. Exhibiting externalizing behaviors increased the risk of receiving a diagnosis, whereas learning-related behaviors and greater academic achievement decreased this risk. Children of mothers aged 39 years or older at the child’s birth, children who had access to health care, and children of English-speaking parents were more likely to receive an ADHD diagnosis.

By the spring of 8th grade, approximately 7% of white children had received an ADHD diagnosis; the comparable rates for children who were African American, Hispanic, or of other races/ethnicities were approximately 3%, 4.4%, and 3.5%, respectively. Minority children with ADHD were much less likely to be using medication than were white children with ADHD.

This study builds on previous reports of racial/ethnic disparities in ADHD diagnosis and treatment, establishing that children who are African American, Hispanic, or of other races/ethnicities are less likely to receive an ADHD diagnosis and subsequent therapy. The results suggest that clinical practice and health policy need to be redirected to ensure that children from minority families undergo appropriate ADHD evaluation, diagnosis, and treatment.

REFERENCE:

1. Morgan PL, Staff J, Hillemeier MM, Farkas G, Maczuga S. Racial and ethnic disparities in ADHD diagnosis from kindergarten to eighth grade. Pediatrics. 2013;132(1):85-93.

CHARLES A. POHL, MD––Series Editor:Dr Pohl is professor of pediatrics and senior associate dean of student affairs and career counseling at Jefferson Medical College in Philadelphia, Pennsylvania.

Dr Jones is a pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.