Results from a systematic review and meta-analysis published in JAMA Psychiatry suggest that Black individuals may be at an increased risk for attention-deficit/hyperactivity disorder diagnoses (ADHD) compared to the general United States population.
Investigators conducted a systematic review of APA PsycInfo, MEDLINE, Embase, Cochrane CENTRAL, CINAHL, ERIC, and Education Source from inception through 2019 for studies describing ADHD prevalence and risk factors in Black patients. Eligible trials had empirical data on the prevalence of ADHD in Black patients and were conducted in countries with Black minority populations. Studies published in English and French were eligible for inclusion. Random-effects meta-analyses were generated to estimate the overall prevalence of ADHD. A narrative review was conducted of all studies to identify key risk factors for ADHD among Black patients.
The final analysis used data from 24 samples described in 21 unique studies. All studies had been conducted in the United States. Publication year ranged from 1979 to 2019. The pooled cohort comprised 154,818 Black individuals. Overall, 2 studies assessed adults (aged ≥18 years), 8 assessed children (0-12 years), 1 assessed adolescents (13-17 years, and 13 assessed both children and adolescents. The pooled prevalence of ADHD was 14.54% (95% CI, 10.64-19.56%). The prevalence among Black patients under the age of 18 years was 13.87% (95% CI, 9.59-19.64%). These figures are high compared to estimates from prior meta-analyses, which suggest a pooled worldwide prevalence ranging from 5% to 7%.
In a narrative review of included studies, the most significant risk factors for ADHD included age, sex, socioeconomic status, and race. While prevalence rates varied across studies, many suggested that ADHD diagnoses were more common among children aged 8-12 years compared to younger (3-7 years) and older (13-17 years) individuals. In both the general population and among Black individuals, boys were significantly more likely to receive a diagnosis of ADHD compared to girls. Boys were also more likely to receive medication for ADHD.
Low socioeconomic status was strongly tied with ADHD across several studies. Interestingly, while high socioeconomic status appeared to be protective against ADHD among white individuals, the same was not observed among Black individuals. Studies also identified racial disparities in the reporting and diagnosis of ADHD. Teachers were more likely to report ADHD symptoms among Black children compared to white children. However, Black parents were less likely to report ADHD symptoms in their children, for fear of racial discrimination in the health care system.
This meta-analysis represents the first attempt to quantify ADHD prevalence among Black individuals in the United States. Contrary to information reported in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), Black individuals appear to be at higher risk for ADHD than the general US population.
Concerning study limitations, the investigators cited between-study heterogeneity, which may affect the reliability of prevalence estimates. Additionally, while age, sex, and socioeconomic status were hypothesized to be moderators of the racial differences in ADHD prevalence, not enough data were available to conduct moderation analyses. Even so, results suggest an unmet need in the United States for ADHD treatment, research, and intervention aimed at Black individuals.
“These results highlight a need to increase ADHD assessment and monitoring among Black individuals from different social backgrounds,” the investigators wrote. “They also highlight the importance of establishing accurate diagnoses and culturally appropriate care.”
Cénat JM, Blais-Rochette C, Morse C, et al. Prevalence and risk factors associated with attention-deficit/hyperactivity disorder among US Black individuals: a systematic review and meta-analysis [published online September 9, 2020]. JAMA Psychiatry. doi: 10.1001/jamapsychiatry.2020.2788