Busting Myths About Black Individuals With ADHD

RESEARCH UPDATE

Previous systematic reviews estimate the prevalence of attention-deficit/hyperactivity disorder (ADHD) worldwide as 5.6% to 7.2%.^1,2 However, there is evidence that some ethnocultural groups, such as Black individuals, are underrepresented in studies.^3,4 One systematic review found a higher prevalence of ADHD in Black than white youth, with evidence for a wide range in individual estimates for Black youth.³ Many factors may contribute to this variability.

Cenat and colleagues⁵ conducted a systematic review and meta-analysis to determine the pooled prevalence estimate of ADHD and associated individual, familial, and social factors among Black individuals, toward evidence-based and culturally adapted programs. The authors search PsychInfo, MEDLINE, Embase, Cochrane CENTRAL, CINAHL, ERIC, and Education Source from inception through October 2019. The search was designed by considering previous systematic review search strategies focused on Black participants. The authors included journal articles published in English or French with empirical data on the prevalence of ADHD samples in Black individuals in countries where they are considered a minority population (eg, United States and Canada).

The authors screened 3833 articles by title/abstract, from which they assessed 99 full-text articles for eligibility. Twenty articles met the inclusion criteria, and an additional article was found by manually searching the reference lists of these articles (DSM-5 criteria are listed in the Table). Thus, 21 studies (24 independent samples), including 2 samples of adults, were included in the meta-analysis, all of which came from the United States.Each study was subjected to a quality assessment. Random effects meta-analysis on the proportion of Black individuals with ADHD was generated.

The included studies had a combined sample size of 154,818. The pooled prevalence of ADHD was 14.5% (95% CI 10.6%-19.6%), with significant between-study heterogeneity. There was no evidence of publication bias based on a funnel plot and Kendall τ rank-order correlation. A similar pooled prevalence of 13.9% was found after excluding the 2 adult samples. Although some individual studies found sociodemographic (eg, age, sex, socioeconomic status), familial, and environmental risk factors, and risk behaviors, there were inadequate data to perform a moderation analysis, so a narrative review was performed. Some replicated risk factors (reported in 3 or more studies) include male sex, Black (versus other) race, low socioeconomic status, and in utero or childhood exposure to toxic substances. The authors conducted the first meta-analysis of the prevalence and risk factors associated with ADHD in Black individuals in the United States. The 14.5% prevalence of ADHD in this population is greater than estimates from previous systematic reviews, suggesting a higher prevalence of ADHD in Black individuals.^2,3

Although low socioeconomic status is a risk factor for ADHD in Black individuals, high socioeconomic status is not a protective factor. The authors noted that findings highlight the need for studies on associations between race and race-associated experiences and the diagnosis, prevalence, and risk factors associated with ADHD. Research on ADHD in other non-US Western countries should take ethnicity into account, and the absence of data from these countries is a limitation of the present study.Another limitation was the absence of inadequate data to quantitatively investigate potential moderating factors (eg, age, sex).

The Bottom Line

Findings from this meta-analysis challenge the notion that Black individuals have a lower prevalence of ADHD than other races. More research is needed to establish accurate diagnoses and culturally appropriate care for Black youth with ADHD.

Dr Miller is professor in the Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric TimesTM. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain and Behavior Research Foundation, and the Stanley Medical Research Institute.

References

1. Polanczyk G, de Lima MS, Horta BL, et al. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164:942-948.

2. Thomas R, Sanders S, Doust J, et al. Prevalence of attention-deficit/ hyperactivity disorder. Pediatrics. 2015;135:e994-e1001.

3. Miller TW, Nigg JT, Miller RL. Attention deficit hyperactivity disorder in African American children: what can be concluded from the past ten years? Clin Psychol Rev. 2009;29:77-86.

4. Moody M. From under-diagnoses to over-representation: black children, ADHD, and the school-to-prison pipeline. J African Am Stud. 2016;20:152-163.

5. Cenat JM, Blais-Rochette C, Morse C, et al. Prevalence and risk factors associated with a ttention-deficity/hyperactivity disorder among US black individuals: a systematic review and meta-analysis. JAMA Psychiatry. 2021;78:21-28.

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA; American Psychiatric Association: 2013.