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23 Aug 2021

Wexler D et al. Clin Neuropsychol 2021; Epub ahead of print

Evidence suggests that race-based diagnostic discrepancies exist for ADHD (Morgan et al, 2013; Morgan et al, 2014; Pastor et al, 2005). This study aimed to evaluate race-based discrepancies in informant ratings and in rates of ADHD diagnosis among a clinically referred sample of Black and White children.

Demographic information and ratings of inattention, hyperactivity/impulsivity and conduct were collected from caregivers and teachers between December 2011 and October 2020 as part of neuropsychological evaluations at an outpatient clinic at a large, urban medical centre. Independent and paired-sample t-tests were carried out to investigate differences in ratings of ADHD symptoms and conduct problems in Black and White children. Three-way between-subjects univariate analyses of variance (ANOVAs) were conducted to assess interactions among race, diagnostic status and socioeconomic status (SES) (i.e. insurance type) on reports of ADHD and conduct symptoms. Chi-square tests were used to investigate differences in the rates of ADHD diagnosis between Black and White children, followed by a binary logistic regression analysis with insurance type, child age, child sex and learning difficulties as covariates.

The final sample included 3943 children (aged 6–18 years), of which 70% were White and 30% were Black. Less than half of the sample (n=1724 [44%]) had a primary or secondary billing diagnosis of ADHD. Of those who were not diagnosed with ADHD, 37.2% had primary billing diagnoses of other mental health disorders and neurodevelopmental disabilities, and 19.1% had primary billing diagnoses of medical conditions.

Caregiver reports of ADHD symptoms and conduct problems

Regarding caregiver reports of inattentive symptoms, no difference was observed between Black and White children (F(1,3.20=0.44; p=0.51). Regardless of ADHD diagnostic status, caregivers of Black children with commercial insurance reported fewer hyperactive/impulsive symptoms (t(2541)=3.28; p=0.001) and conduct problems (t(2530)=3.63; p<0.001) than those of White children with commercial insurance. Similar levels of hyperactive/impulsive symptoms (t(791)=-0.19; p=0.85) and conduct problems (t(783)=0.06; p=0.95) were reported by caregivers of children with medical assistance, regardless of race.

Teacher reports of ADHD symptoms and conduct problems

For teacher reports of inattentive symptoms, teachers rated Black children as having more inattentive symptoms than White children, regardless of child insurance type, age, sex, learning difficulties and diagnosis of ADHD (F(1,14.66=1.68; p=0.2). A 2 (race) by 2 (insurance type) ANOVA split by diagnostic status indicated a significant interaction between race and insurance type only within the group of children diagnosed with ADHD who showed hyperactive/impulsive symptoms (F(1,1511)=5.97; p=0.015). T-tests showed that, for children with a diagnosis of ADHD, Black children with medical assistance were rated as having more hyperactive/impulsive symptoms than White children with medical assistance (t(412)=-2.84; p=0.005). When teacher-reported conduct problems were examined with race, diagnostic status and insurance type, there was a main effect of race (F(1,3324)=26.35; p<0.001) as Black children were rated as having more conduct problems, regardless of their diagnostic status, insurance type, age, sex or learning difficulties.

Regardless of ADHD diagnostic status and child race, caregivers reported more symptoms of inattention, hyperactivity/impulsivity, and conduct problems than teachers did for the same children (p<0.001 for all).

Rates of ADHD diagnosis

Despite differences in teachers’ ratings by race, rates of ADHD diagnoses within the sample did not differ by child race (B=-0.09, standard error [SE] B=0.07, Chi-square: 1.79; p=0.18), with similar proportions of Black (n=539/1189, 45%) and White (n=1185/2754, 43%) children receiving a diagnosis of ADHD. The authors suggested that this similarity in diagnostic rates indicates that Black and White children within the clinic received ADHD diagnoses at similar rates, regardless of insurance type and other important covariates.

There were several limitations of this study. Firstly, the results only represent a sample of children who were referred for neuropsychological evaluation, and the sample selection was non-random, since children were only included in the study if ratings were completed by both their caregiver and teacher. Another limitation was that school environment and teacher characteristics, which are likely to influence a teacher’s appraisal of child behaviour (Jung, 2020), were not included as covariates in the analyses. Furthermore, the sample did not control for provider characteristics, which may have impacted informant ratings and diagnostic decisions. Moreover, the definition of SES was another limitation of this study and only allowed for sparing interpretations to be made. Finally, there were no data available on how clinicians diagnosed ADHD in the current study, therefore discrepancies in diagnostic criteria may have been present.

To conclude, the authors confirmed that in this study, teachers reported more ADHD and conduct problems in Black children. This was hypothesised to potentially reflect teacher bias rather than actual prevalence differences by race, since this disparity was not present when comparing the reports of Black caregivers with White caregivers. The authors noted that the lack of racial disparities in rates of ADHD diagnoses in this study was inconsistent with findings in community- and population-based samples, therefore reflecting possible benefits of the use of neuropsychological evaluations in diagnostic decision-making for ADHD.

Read more about race-based discrepancies in children with ADHD here

Disclaimer: The views expressed here are the views of the author(s) and not those of Takeda.

Jung ST. Contextualized effects of racial/ethnic matching between students and teachers in urban, suburban, and rural high schools. Teach Coll Rec 2020; 122: 1-34.

Morgan PL, Hillemeier MM, Farkas G, et al. Racial/ethnic disparities in ADHD diagnosis by kindergarten entry. J Child Psychol Psychiatry 2014; 55: 905-913.

Morgan PL, Hillemeier MM, Farkas G, et al. Racial and ethnic disparities in ADHD diagnosis from kindergarten to eighth grade. Pediatrics 2013; 132: 85-93.

Pastor PN, Reuben CA. Racial and ethnic differences in ADHD and LD in young school-age children: parental reports in the National Health Interview Survey. Public Health Rep 2005; 120: 383-392.

Wexler D, Salgado R, Gornik A, et al. What’s race got to do with it?: informant rating discrepancies in neuropsychological evaluations for children with ADHD. Clin Neuropsychol 2021; Epub ahead of print.

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