Closing Diagnostic and Treatment Gaps in Black Children With ADHD

Disparities in the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) affected Black school-age children at personal, interpersonal, and structural levels, according to Kakra Boye-Doe, MD. “We have an underdiagnosis of Black youth with ADHD, and they tend to require more symptoms to get diagnosed,” Boye-Doe said.¹ Black youth were also less likely to be offered evidence-based treatment.² Boye-Doe attributed these disparities to a legacy of racism and medical mistrust. They carried real-life consequences, including earlier death among Black children compared with their peers.

Stigma and medical mistrust also limited continuation of treatment. Families sometimes avoided reporting behavioral problems to a physician because the report could add another label for the child. Historical events, including the Tuskegee study and diagnostic practices that framed behaviors displayed by Black patients as symptoms of disorder, shaped the expectations Black families brought to clinical encounters. Boye-Doe emphasized that clinicians needed to acknowledge this context. Mistrust made engagement in treatment more difficult and raised concern among families about the label a child might receive.

Accurate diagnosis mattered because of a historical overdiagnosis of disruptive behavior disorders in Black youth, which Boye-Doe said required correction. In the present, a diagnosis of a disruptive behavior disorder could lead to a child being seen as an adult and was accompanied by parent blame and overcriminalization in the legal system. No clear evidence-based treatment existed for disruptive behavior disorders, and clinicians often turned to other conditions that might be driving the behavior. ADHD, in contrast, had a clear treatment pathway. Stimulants had efficacy up to 90%, school-based interventions such as a 504 plan or an individualized education program were helpful, and parent management training was also available. Treatment effectiveness made timely diagnosis of ADHD in Black youth a priority. “We also know that early diagnosis and management is likely to mitigate the risk towards overcriminalization in legal systems,” Boye-Doe said.

Dr Boye-Doe is a second-year child and adolescent psychiatry fellow at Lurie Children’s Hospital.

References

1. Coker TR, Elliott MN, Toomey SL, et al. Racial and ethnic disparities in ADHD diagnosis and treatment. Pediatrics. 2016;138(3):e20160407.

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