Underdiagnosis of ADHD begins early for some groups

• Minority children are less likely than their white peers to receive an ADHD diagnosis
• The gap persisted even after researchers controlled for health insurance coverage and other factors
• Increased awareness and questioning by physicians%2C school psychologists and teachers is needed

Prior research has shown that black, Hispanic and other minority children are less likely than comparable white children to be diagnosed with attention-deficit hyperactivity disorder, but a new study shows that this disparity starts as early as kindergarten and continues through middle school.

Among those diagnosed with ADHD — the most common mental health condition among kids and teens — children who are ethnic or racial minorities are less likely to use prescription medication for the disorder, even when researchers account for such factors as health insurance coverage, socio-economic status and academic achievement.

The findings showed that "at every time period that was assessed," disparities in diagnosis and medication use "were evident across all of the racial and ethnic groups that we analyzed," says Paul Morgan, lead author of the study published in the July issue of the journal Pediatrics and online today.

"Other research has already identified a range of different effective treatments for ADHD, including medication, behavioral therapy, specialized educational programming and parent training," says Morgan, an associate professor of education at Penn State University. "These findings suggest that children who are racial and ethnic minorities are not accessing those treatments because they are comparatively underdiagnosed.

"There's no reason to think that minority children are less likely to have ADHD than white children, so these are worrisome findings that suggest a systemic problem," he says, in terms of health care professionals and school-based professionals not meeting the needs of these families when it comes to properly evaluating, diagnosing and providing effective treatment.

Using the nationally representative Early Childhood Longitudinal Study: Kindergarten Class of 1998–1999, Morgan and colleagues analyzed data collected by the federal government on 17,100 children based on parent reports. Among the findings:

•By the spring of middle school, about 7% of white children had received an ADHD diagnosis sometime between kindergarten and eighth grade. Comparable rates for black, Hispanic and other races/ethnicities (including Asian, Native Hawaiian, Pacific Islander, American Indian, Alaskan native and those described as being more than one race) were about 3%, 4.4% and 3.5%, respectively.

•Compared with whites, the odds of ADHD diagnosis were 69% lower for black kids, 50% lower for Hispanic kids and 46% lower for children of other race/ethnicities.

•Boys had twice the odds of girls of being diagnosed, regardless of race or ethnicity; and engaging in fighting, bullying and similar problem behaviors increased the odds of diagnosis.

•Among children diagnosed, prescription medication use was lower for children of all racial and ethnic minorities, compared with white children. The odds were 47% lower for Hispanic kids, 65% lower for black kids and 51% lower for children of other race/ethnicities.

The data used in this study "unfortunately can't appropriately begin to address the reasons for these differences," but "the idea that ethnic majority parents seek biopsychosocial services more frequently than ethnic minority parents is consistent with findings from prior studies," says John Carlson, professor of school psychology at Michigan State University. He was not involved in the study.

Whether or not parents pursue diagnosis and treatment for a child's ADHD involves not only access to insurance but also "values and beliefs about psychological disorders and their treatments," Carlson says.

Research he has conducted identified a lack of culturally competent health care providers, financial hurdles and "insufficient dissemination of information about effective treatments" as key barriers to minority families' effective use of ADHD treatments.

In May, the Centers for Disease Control and Prevention reported that ADHD was the most prevalent mental health disorder affecting children, including nearly 7% of kids ages 3 to 17, or about 4.2 million.

The new paper in Pediatrics notes that additional research is needed to determine the extent to which some populations may be overdiagnosed for ADHD.