Study data published in JAMA Network Open outline racial disparities in the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children. In a nationwide cohort study conducted in the United States, ADHD diagnosis was significantly more common among White children compared with Asian, Hispanic, and Black children. Additionally, White children were more likely than their peers to receive behavioral therapy or medications for ADHD.
Investigators conducted a retrospective cohort study of children born in the US between January 1, 2006 and December 31, 2012. Data were extracted from the OptumLabs Data Warehouse, which comprises medical and pharmacy claims for commercial and Medicare Advantage enrollees. The outcome of interest was a diagnosis of ADHD, identified using associated diagnostic codes. Secondary outcomes included any treatment for ADHD, including behavioral and pharmacologic.
The primary exposure was race/ethnicity, defined by self-report. Annual household income and geographic area of residence were also captured. Cox proportional hazards models were used to calculate the hazard ratio (HR) of ADHD among non-White children compared with White children. Models were adjusted for sex, household income, and area of residence.
The total study cohort included 238,011 children, among whom 116,093 (48.8%) were girls. The racial/ethnic distribution was as follows: 173,082 (72.7%) White; 23,358 (9.8%) Hispanic; 15,183 (6.7%) Asian; and 14,792 (6.2%) Black.
A total of 11,401 children (4.8%) were diagnosed with ADHD during follow-up. Mean age of diagnosis was 6.5 (±1.9) years. The cumulative incidence of ADHD at age 12 years was 13.12% (95% CI, 12.79-13.46). The majority (78.8%) of children diagnosed with ADHD were White. Compared to White children, the adjusted HRs for ADHD were 0.48 (95% CI, 0.43-0.53) among Asian children; 0.83 (95% CI, 0.77-0.90) among Black children; and 0.77 (95% CI, 0.72-0.82) among Hispanic children.
Girls were less likely to be diagnosed compared with boys (HR, 0.40; 95% CI, 0.38-0.41). Lower incidence of ADHD was also associated with residence in the Midwest (HR, 0.77; 95% CI, 0.72-0.82) and West (HR, 0.64; 95% CI, 0.60-0.69) compared with the Northeast. ADHD was less often diagnosed in high-income households compared with low-income households, with the lowest incidence observed in households earning $200,000 annually or more.
Among preschool-aged children diagnosed with ADHD, 19.4% received behavioral therapy, 32.4% received medication, 19.0% received both, and 774 (29.2%) had no record of ADHD treatment. Among school-aged children with ADHD, 65.6% received medications, 14.4% received therapy, and 20.0% reported no treatment. White children were more likely than other groups to receive treatment for ADHD. Asian children had the highest odds of no treatment compared to White children (odds ratio [OR], 0.54; 95% CI, 0.42-0.70).
Results from this study underscore racial and ethnic disparities in the diagnosis and treatment of ADHD in the US.
Study limitations include the use of an insurance database to identify cohort participants, which naturally excludes children without insurance. Additionally, data were not available for ADHD therapies not covered by insurance, which may have led to an underreporting of treatment receipt.
“Future study is needed to elucidate the mechanism behind these disparities,” investigators wrote. “Clinicians should provide racially and culturally sensitive care in the evaluation and treatment of ADHD to ensure all children receive appropriate care.”
Shi Y, Hunter Guevara LR, Dykhoff HJ, et al. Racial disparities in diagnosis of attention-deficit/hyperactivity disorder in a US national birth cohort. JAMA Netw Open. 2021;4(3):e210321. doi:10.1001/jamanetworkopen.2021.0321