Racial and Ethnic disparities in ADHD diagnosis

Black children and children in homes where a language other than English is spoken are less likely to receive an attention-deficit/hyperactivity disorder (ADHD) diagnosis by school entry, despite being otherwise similar to white children on many measured background characteristics, according to a study by a team of researchers.

Their findings indicate that disparities in ADHD diagnosis begin to occur early in children's school careers.

Paul Morgan

"We were interested in evaluating whether the disparities observed across elementary and middle school in our earlier study were evident as early as the fall of kindergarten, accounting for many factors measured prior to the children entering school," said Paul Morgan, associate professor of special education, Penn State.

"Whether these disparities extend to Hispanic children has also been unclear. We find that their initially observed disparities are related to non-English language use in the home."

Analyses of kindergarten teacher-reported classroom behaviour indicated that neither black nor Hispanic children displayed less frequent ADHD-related behaviours than white children, suggesting that a lower incidence of ADHD symptomology did not explain minority children's comparatively lower rates of diagnosis.

"One explanation for our findings is that black parents may be relatively more reluctant to obtain a mental health diagnosis for their children, while language barriers may explain Hispanic children's lower likelihood of diagnosis," Morgan said.

"It may also be the case that pediatricians and other professionals are not soliciting developmental concerns as often from minority families."

A lack of treatment for ADHD may result in some minority children experiencing more learning and behavioral problems as they start school, so that they quickly begin falling behind their peers.

"One practical application is that these groups of children may have unmet treatment needs," Morgan said.

"Pediatricians, psychiatrists and school-based practitioners should be sensitive to the possibility that cultural and linguistic barriers are resulting in systematic under-diagnosis for some groups of children."

"Ensuring minority children are appropriately diagnosed and treated for ADHD may require overcoming these barriers."

Providing minority parents with information on recognizing potential ADHD symptoms in their children, as well as encouraging help-seeking behaviours when meeting with professionals, may also help prevent or reduce racial/ethnic diagnosis disparities.

"I hope that our findings inform efforts to help all children with ADHD," Morgan said. "If untreated, ADHD can very quickly begin to interfere with children's opportunities for school success."

More information: "Racial/ethnic disparities in ADHD diagnosis by kindergarten entry." Morgan PL, Hillemeier MM, Farkas G, Maczuga S. J Child Psychol Psychiatry. 2014 Jan 24. DOI: 10.1111/jcpp.12204. [Epub ahead of print]

Autism: Racial and Ethnic disparities in specialty services

A study from investigators at MassGeneral Hospital for Children (MGHfC) found that African-American or Hispanic children diagnosed with autism were significantly less likely than white children to have received subspecialty care or procedures related to conditions that often accompany autism spectrum disorders.

While previous studies have documented that minority children with autism tend to be diagnosed at a later age than white children, this report – which will appear in the July issue of Pediatrics and has been released online – is the first to describe disparities in the use of specialty services in gastroenterology, psychiatry or psychology.

"We think there are probably many reasons for these differences," says Sarabeth Broder-Fingert, MD, of MGHfC and the Center for Child and Adolescent Health Research and Policy at Massachusetts General Hospital (MGH), lead author of the report.

"Many autism-related medical symptoms – including gastrointestinal issues like constipation and neuro-psychiatric issues such as anxiety or sleep disorders – are not well understood, so doctors may not realize children are having those symptoms."

The research team reviewed records for more than 3,600 patients ages 2 to 21 with a diagnosis of autism who received care at the MGH or its affiliated health centers from 2000 through 2010.

Data on each clinical visit was analyzed, with particular attention to specialty care in gastroenterology, psychiatry and psychology and to procedures including endoscopy, ultrasound, EEG, brain imaging and sleep studies.

Among the patients identified, 81 percent were white, 5 percent were African-American and 7 percent, Hispanic.

The analysis revealed that minority children were significantly less likely to have received either subspecialty care or procedures, with some of the most significant differences in gastroenterology services, which were accessed by almost 14 percent of white children but only 9 percent of African-American children and 10 percent of Hispanic children.

Minority children were less likely to have received an endoscopy or colonoscopy, and Hispanic children were much less likely to have had sleep studies or other neurological or neuropsychiatric tests.

"We know that many children with autism have gastrointestinal or sleep issues, and if those problems are not being diagnosed or treated, they can lead to additional behavior difficulties that can inhibit development," says Broder-Fingert, who is a clinical fellow in Pediatrics at Harvard Medical School.

"Combining the challenges of accessing specialty services for any child with autism, regardless of race or ethnicity, with the recognized difficulties minority communities have accessing medical care in general can lead to these major disparities in the use of services.

"It's going to be important to see whether these differences in service use lead to differences in medical and behavioral outcomes, and we need to understand more about why this is happening," she adds.

"We hope this work can help doctors be aware of these disparities and be sure to look out for patients – especially minority patients – who might need specialty services, and that we can help parents of children with autism be aware that these conditions may occur in their children and ask their doctors for assistance."