WK 8 SOCW 6443 Assignment: Addressing Ethical Implications in the Treatment of ADHD

ARTICLEPEDIATRICS Volume 138 , number 3 , September 2016 :e 20160407

Racial and Ethnic Disparities in ADHD Diagnosis and Treatment Tumaini R. Coker, MD, MBA, a, b Marc N. Elliott, PhD, b Sara L. Toomey, MD, MPhil, MPH, MSc, c David C. Schwebel, PhD, d Paula Cuccaro, PhD, e Susan Tortolero Emery, PhD, e Susan L. Davies, PhD, f Susanna N. Visser, DrPH, MS, g Mark A. Schuster, MD, PhDb, c

abstractOBJECTIVES: We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities

were more likely due to underdiagnosis or undertreatment of African-American and Latino

children, or overdiagnosis or overtreatment of white children.

METHODS: We used a population-based, multisite sample of 4297 children and parents

surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression

examined disparities in parent-reported ADHD diagnosis and medication use in the

following analyses: (1) using the total sample; (2) limited to children with an ADHD

diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms.

RESULTS: Across all waves, African-American and Latino children, compared with white

children, had lower odds of having an ADHD diagnosis and of taking ADHD medication,

controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental

health symptoms. Among children with an ADHD diagnosis or symptoms, African-American

children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino

children had lower odds at fifth and 10th grades. Among children who had neither ADHD

symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD

diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted

analysis.

CONCLUSIONS: Racial/ethnic disparities in parent-reported medication use for ADHD are

robust, persisting from fifth grade to 10th grade. These findings suggest that disparities

may be more likely related to underdiagnosis and undertreatment of African-American and

Latino children as opposed to overdiagnosis or overtreatment of white children.

aDepartment of Pediatrics, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles,

California; bRAND, Santa Monica, California; cDivision of General Pediatrics, Boston Children’s Hospital and

Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Departments of dPsychology and fHealth Behavior, University of Alabama at Birmingham, Birmingham, Alabama; eCenter for Health Promotion

and Prevention Research, University of Texas–Houston, School of Public Health, Houston, Texas; and gCenters

for Disease Control and Prevention, Atlanta, Georgia

Dr Coker was responsible for study conception and design, data analysis, interpretation of

fi ndings, and writing of the manuscript; Dr Elliott contributed to study conception and survey

development, obtained funding, and participated in study design, analysis, and interpretation;

he also revised manuscript drafts; Dr Schwebel contributed to study conception and survey

development, obtained funding, participated in study design and interpretation, and revised

manuscript drafts; Drs Toomey, Tortolero Emery, Cuccaro, and Davies contributed to study

conception and survey development, obtained funding, participated in study design, and revised

manuscript drafts; Dr Visser contributed to study conception, study design, and revision of

manuscript drafts; and Dr Schuster contributed to study conception and survey development,

To cite: Coker TR, Elliott MN, Toomey SL, et al. Racial and Ethnic Disparities in ADHD Diagnosis and Treatment.

Pediatrics. 2016;138(3):e20160407

WHAT’S KNOWN ON THIS SUBJECT: There are racial/ethnic disparities in medication use for

attention-defi cit/hyperactivity disorder (ADHD), but

it is unknown if the disparity is more likely due to

an underdiagnosis or undertreatment of African-

American and Latino children, or an overdiagnosis

or overtreatment of white children.

WHAT THIS STUDY ADDS: Racial/ethnic disparities in medication use for ADHD are robust, persist

from fi fth to 10th grade, and seem to be more

related to underdiagnosis and undertreatment of

African-American and Latino children as opposed to

overdiagnosis or overtreatment of white children.

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COKER et al

Attention-deficit/hyperactivity

disorder (ADHD) diagnoses have

been increasing in the United States.

Parent-reported rates of ever

receiving a diagnosis for children

aged 4 to 17 years increased from

7.8% in 2003 to 11.0% in 2011,

and rates of ADHD medication use

increased from 4.8% in 2007 to

6.1% in 2011. 1 Studies also describe

racial/ethnic disparities in diagnosis

and medical treatment of ADHD,

indicating that African-American

and Latino children may have lower

rates of receiving a diagnosis and

medication compared with white

children. 2 – 7

These differences in diagnosis and

treatment are generally interpreted

as reflecting underdiagnosis and

undertreatment of African-American

and Latino children. 5, 6 In light of

the increasing prevalence, however,

researchers have recognized that

overdiagnosis or overtreatment

of white children is a possible

alternative explanation for the

disparity, 3, 8 although previous

studies have not examined which

explanation is most likely.

The current study was conducted

to help address this question: Is

the disparity in ADHD diagnosis

and medication treatment more

likely due to an underdiagnosis

or undertreatment of African-

American and Latino children or

an overdiagnosis or overtreatment

of white children? A population-

based, multisite longitudinal survey

was used to examine racial/ethnic

disparities in the diagnosis of ADHD

and in ADHD medication treatment

among children. We also examined

whether the disparity and the likely

main drivers of the disparity changed

from fifth grade to 10th grade.

METHODS

Healthy Passages is a longitudinal

study of a cohort of 5147 fifth-

graders and their parents (2004–

2006), with follow-up in seventh

grade (2006–2008) and 10th grade

(2009–2011). 9, 10 Institutional review

board approval was obtained at each

study site and the Centers for Disease

Prevention and Control.

Study Population and Sampling Procedure

Participants were recruited from

public schools in the following

districts: 10 contiguous public school

districts in and around Birmingham,

Alabama; 25 contiguous public school

districts in Los Angeles County,

California; and the largest public

school district in Houston, Texas.

Eligible schools had an enrollment

of ≥25 fifth-graders, representing >99% of students enrolled in regular

classrooms. To ensure adequate

sample sizes of African-American,

Latino, and white students, a 2-stage

probability sampling procedure,

detailed elsewhere, 9 was used. The

sampling procedure included the

following: (1) random sampling of

schools using probabilities that were

a function of how closely a school’s

racial/ethnic mix corresponded to

the site’s racial/ethnic target; and (2)

invitation to participate to all fifth-

grade students in regular classrooms

of sampled schools.

The 118 sampled schools had 11 532

enrolled fifth-graders. A primary

caregiver (henceforth referred to as

“parent”) for each student received

a letter requesting permission for

contact by study personnel. Of the

11 532 parents, 6663 who either

agreed to be contacted or who were

unsure were invited to participate;

5147 completed an interview at

baseline (fifth grade), and 4297

parent–child dyads participated in

all 3 waves (at fifth grade and ∼2 and 5 years later, when most children

were in seventh and 10th grades,

respectively).

Our sample size reached the

predetermined sample size targets;

details of statistical power are

described elsewhere. 9 Interviews

were conducted at the home, a study

center, or another preferred location.

Parents provided informed consent

for participation, and children gave

assent.

Measures

ADHD Symptoms

Questions from the Diagnostic

Interview Schedule for Children

Predictive Scales (DPS) were used

to assess the presence of parent-

reported symptoms of ADHD and

other mental health conditions that

may be comorbidities which could

affect whether a child receives a

diagnosis or medication for ADHD.

These comorbidities included

oppositional defiant disorder,

conduct disorder, and depression.

The DPS is a screening tool based on

the Diagnostic Interview Schedule

for Children; it relies on parent-

reported symptoms (reported as

present or not) of ADHD (7 yes/

no items), oppositional defiant

disorder (12 yes/no items), and

conduct disorder (8 yes/no items),

as well as child-reported symptoms

of depression (6 yes/no items)

during the previous 12 months

(sensitivities and specificities for

ADHD, oppositional defiant disorder,

conduct disorder, and depression,

≥0.89). 11 The 7 ADHD symptoms in the DPS align with 5 inattentive

symptoms (eg, Has your child often

had trouble finishing his or her

homework or other things he or she

is supposed to?) and 2 hyperactivity/

impulsivity symptoms (eg, Has your

child often left his or her seat when

he or she was not supposed to?) on

the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 12 A dichotomous variable was created

for symptoms consistent with

ADHD, defined by a score (sum of

symptoms) above the sample 90th

percentile. We used this cutoff value,

which was more stringent than cutoff

values used in a previously studied

community sample, 11 because data

on level of impairment or symptom

severity were not collected. For

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PEDIATRICS Volume 138 , number 3 , September 2016

fifth- and seventh-grade surveys,

the 90th percentile corresponds

to positive responses on ≥6 of 7 possible ADHD symptoms. For

the 10th-grade surveys, the 90th

percentile corresponds to ≥5 of 7 possible symptoms. Of note, the

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, requires ≥6 symptoms of inattention and/or hyperactivity-impulsivity for

youth aged ≤16 years or ≥5 for youth aged ≥17 years. 12 We also created a continuous variable for symptoms

consistent with ADHD and each of

the other mental health disorders,

defined by the total symptom score

for each scale. Higher symptom

scores reflect more symptoms.

ADHD Diagnosis

In survey waves 1 and 3, parents

were asked if a physician or health

professional had ever told them

that their child had hyperactivity or

attention-deficit disorder (wave 1

question) or hyperactivity, attention-

deficit disorder, or ADHD (wave 3

question) (response options, yes or

no). This question was not asked in

wave 2.

ADHD Medication Use

In waves 1 through 3, parents were

asked if during the last year (wave 1)

or past 12 months (waves 2 and 3)

their child had taken medication for

being overactive, being hyperactive,

or having trouble paying attention

(yes or no).

Other Variables

Data were collected on several child

and parent wave 1 characteristics

previously hypothesized to influence

mental health care use. 13 – 15 Child

sociodemographic covariates

included study city (Birmingham,

Houston, and Los Angeles), child

race/ethnicity (non-Latino black

[henceforth, African-American],

Latino, non-Latino white, and other

race/ethnicity), age at fifth grade

survey (<11, 11, and ≥12 years), sex (male or female), insurance status

(uninsured or insured), annual

household income (less than $20 000,

$20 000–$34 000, $35 000–$69 999,

$70 000 or higher), and household

composition (2-parent, 1-parent, or

other). Parent sociodemographic

covariates included highest

household education level (no high

school diploma, high school diploma,

some college, and college degree

or greater) and English language

proficiency (speaks English very well

versus less than very well). Because

no significant differences were

found in results when accounting for

household size in the income variable

(by using the federal poverty level),

we used annual household income.

We also included child symptoms

of oppositional defiant disorder,

conduct disorder, and depression

(each as continuous variables),

and the child’s school functioning,

using the Pediatric Quality of Life

Inventory version 4.0 at each wave.

This inventory tool is a well-validated

instrument designed to measure

health-related quality of life in 2- to

18-year-olds. 16 It measures school

functioning by using 5 child-reported

items (hard to pay attention in class,

forgets things, trouble keeping up

with school work, missed school

because not feeling well, and missed

school to go to physician/hospital);

respondents report how much of a

problem each item has been during

the past month, with 5 response

options (never, almost never,

sometimes, often, and almost always

a problem). Items are reverse scored

(ie, higher scores represent better

school functioning) and linearly

transformed to a 0 to 100 range.

We included a dichotomous measure

of receipt of family-centered care

(FCC) collected by wave 3 parental

report. FCC is a key element of

the medical home, is less likely to

be reported by African-American

and Latino parents, and may be

associated with having fewer unmet

medical needs. 17 – 19 Although FCC

was only measured in wave 3, it was

used as a covariate in analyses of

all waves, as a general indicator of

access to FCC. FCC was indicated as

received if the parent reported that

their child’s physicians “always”

or “usually” spent enough time,

listened carefully, were sensitive

to the family’s values and customs,

provided specific information that

the parent needed, and helped

the parent feel like a partner in

their child’s care; this method of

assessing FCC has been used in

multiple studies. FCC is included in

the National Survey of Children’s

Health and the National Survey of

Children with Special Health Care

Needs, 20, 21 and it has been shown

to be stable over multiple waves of

these national surveys. 22 However,

because we cannot know whether

FCC measured at wave 3 is indicative

of care received at waves 1 and 2, a

sensitivity analysis was conducted

to determine whether inclusion of

FCC as a covariate in adjusted models

significantly changed our results.

Statistical Methods

All analyses use design and

nonresponse weights and account

for the effects of weights and

clustering of children within sites by

using Stata SE 10. 23 – 25 Our sample

included 4297 parent–child dyads

that participated in all 3 waves.

We used χ2 tests of homogeneity and t tests to describe the wave 1 characteristics of children and

parents in the study sample. Bivariate

analyses were also used to describe

the proportion of children with

symptoms consistent with ADHD,

parent-reported diagnosis of ADHD,

and a history of parent-reported

medication for ADHD according to

child race/ethnicity and survey wave.

The proportion of children receiving

ADHD medication was examined

according to race/ethnicity at each

wave, stratified according to number

of ADHD symptoms (0 symptoms,

1–2 symptoms, 3–5 symptoms, and

6–7 symptoms). Logistic regression

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COKER et al

was used to examine the unadjusted

and adjusted odds of ADHD diagnosis

and medication use according to

race/ethnicity over the 3 survey

waves. To determine the disparity

in medication use among children

who had received a diagnosis, odds

of medication use were calculated

according to race/ethnicity among

children with a diagnosis of ADHD

(with or without symptoms).

Finally, we looked for racial/ethnic

disparities in medication use among

2 groups of children: (1) those with a

presumed need for ADHD medication

(either an ADHD diagnosis or

symptoms suspicious for ADHD); and

(2) those with no presumed need

for ADHD medication (no diagnosis

of or symptoms consistent with

ADHD by fifth grade). Racial ethnic/

disparities in medication use that

persist in this first group of children

would suggest underdiagnosis or

undertreatment of African-American

and Latino children. Disparities

that persist in the second group of

children would suggest overdiagnosis

or overtreatment of white children,

which could be the result of multiple

factors (eg, differential provider or

parental expectations for medication

use among children based on child

race/ethnicity).

RESULTS

Table 1 describes the sample. In fifth

grade, parents reported that 8% of

children had symptoms of ADHD, 8%

had ever received an ADHD diagnosis,

and 7% had taken medication for

ADHD over the past year. By 10th

grade, those percentages increased

to 9%, 9%, and 8%, respectively. In

fifth, seventh, and 10th grades, higher

percentages of African-American

children compared with white

children had symptoms suggestive

of ADHD (fifth grade, 12% vs 7%;

seventh grade, 11% vs 6%; and 10th

grade, 13% vs 9%). Latino children

were just as likely to have ADHD

symptoms as white children at each

wave ( Table 2).

In fifth and 10th grades, white

children were much more likely

to have ever received a diagnosis

of ADHD (16% in fifth grade and

19% in 10th grade) than African-

American children (9% and 10%,

respectively), Latino children (4%

and 4%), and children of other race/

ethnicity (10% and 10%) ( Tables

2 and 3). White children were also

more likely to have a parental report

of taking medication for ADHD in the

last year at all 3 waves, compared

with African-American, Latino, and

other children ( Table 3). Results for

differences in medication use were

similar when stratified according

to number of ADHD symptoms. At

all symptom levels above zero, a

higher proportion of white children,

compared with African-American

and Latino children, had a parental

report of ADHD medication (see

Supplemental Table 6). This disparity

persisted even among children at

the highest symptom levels. For

example, among 10th grade children

at the highest symptom level, 65%

4

TABLE 1 Fifth Grade Characteristics

Characteristic Unweighted N Weighted % or Mean ± SD

Child race/ethnicity

African-American 1497 29.1

Latino 1512 44.4

Othera 248 4.4

White 1039 22.1

Male sex 2097 51.1

Age (child age at fi fth grade)

≤10 y (most aged 10; n = 16 are 8–9 y) 1989 44.0 11 y 2048 48.9

≥12 y 260 7.1 Highest household education

Some high school 755 23.5

High school graduate 850 21.8

Some college 1159 25.2

College graduate 1474 29.5

Household income, $

<20 000 1306 35.4

20 000–34 000 865 23.0

35 000–69 000 857 20.1

≥70 000 1059 21.5 Family household composition

Two-parent 2400 58.1

Single-parent 1685 37.7

Other (nonparent, foster) 190 4.2

Insurance type (child)

Private 2063 42.5

Medicaid/CHIP 1664 42.3

Other insurance type (military, IHS) 80 2.0

Uninsured 472 13.2

Study site

Birmingham, AL 1350 31.0

Houston, TX 1462 34.6

Los Angeles, CA 1485 34.4

Mental health symptoms

Oppositional defi ant disorder 329 7.8

Conduct disorder 350 8.2

Depression 307 7.5

FCC 2176 48.9

School functioning (PedsQL subscale) — 75.0 ± 20.6

CHIP, Children’s Health Insurance Program; IHS, Indian Health Service; PedsQL, Pediatric Quality of Life Inventory; —,

continuous variable. a The other category includes multiracial (n = 131), American Indian/Alaska Native (n = 7), and Asian or Pacifi c Islander

(n = 110).

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PEDIATRICS Volume 138 , number 3 , September 2016

of white children were taking ADHD

medication according to parental

report, compared with 36% of

African-American children and 30%

of Latino children.

Across all waves, African-American

children had significantly lower

adjusted odds of both ever having

a diagnosis of ADHD (fifth grade

adjusted odds ratio [aOR], 0.40 [95%

confidence interval (CI), 0.27–0.59];

10th grade aOR, 0.42 [95% CI,

0.27–0.67]) and of taking ADHD

medication in the past year (fifth

grade aOR, 0.43 [95% CI, 0.29–0.65];

seventh grade aOR, 0.41 [95% CI,

0.28–0.62]; 10th grade aOR, 0.44

[95% CI, 0.28–0.71]) compared with

white children. A similar pattern was

observed when comparing Latino

children versus white children

on adjusted odds of ever having a

diagnosis of ADHD (fifth grade aOR,

0.37 [95% CI, 0.22–0.60]; 10th grade

aOR, 0.46 [95% CI, 0.26–0.79]) and

of taking ADHD medication (fifth

grade aOR, 0.40 [95% CI, 0.23–0.70];

seventh grade aOR, 0.43 [95% CI,

0.25–0.74]; 10th grade aOR, 0.41

[95% CI, 0.21–0.79]) ( Table 3). Of

note, male sex was consistently

associated in these models with

receiving an ADHD diagnosis and

medication.

Disparities in Medication Rates Among Children With ADHD According to Symptoms or Diagnosis

Among children ever having a

diagnosis of ADHD or past-year

symptoms of ADHD, African-American

children had lower adjusted odds

of past-year ADHD medication,

compared with white children at

fifth grade (aOR, 0.33 [95% CI,

0.17–0.62]), seventh grade (aOR,

0.34 [95% CI, 0.18–0.64]), and 10th

grade (aOR, 0.41 [95% CI, 0.22–0.75]).

Latino children had decreased odds

compared with white children at fifth

grade (aOR, 0.38 [95% CI, 0.16–0.90])

and 10th grade (aOR, 0.42 [95% CI,

0.20-0.86]) only ( Table 4).

When examining disparities in

medication use among children who

had been diagnosed with ADHD

(whether they had symptoms),

African-American children (fifth

grade odds ratio [OR], 0.46 [95% CI,

0.22–0.97]; 10th grade OR, 0.42 [95%

CI, 0.24–0.74]) and Latino children

(fifth grade OR, 0.17 [95% CI, 0.07–

0.39]; 10th grade OR, 0.28 [95% CI,

0.14–0.57]) had lower unadjusted

5

TABLE 2 ADHD Symptoms, Diagnosis, and Medication Use According to Race/Ethnicity Over 3 Waves

Variable Fifth Grade Seventh Grade 10th Grade

ADHD, by symptoms

Total 8 (350) 7 (324) 9 (400)

White 7 (68) 6 (67) 9 (87)

African-American 12 (176) 11 (154) 13 (195)

Latino 6 (90) 6 (89) 6 (95)

Other 7 (16) 6 (14) 9 (23)

P <.001 <.001 <.001 ADHD, by diagnosis

Total 8 (368) NA 9 (422)

White 16 (152) NA 19 (191)

African-American 9 (131) NA 10 (139)

Latino 4 (62) NA 4 (69)

Other 10 (23) NA 10 (23)

P <.001 <.001 Took medication for ADHD (past 12 mo)

Total 7 (314) 7 (336) 8 (341)

White 14 (132) 14 (142) 16 (155)

African-American 9 (123) 9 (124) 8 (110)

Latino 3 (44) 3 (55) 4 (60)

Other 7 (15) 6 (15) 7 (16)

P <.001 <.001 <.001

Unless otherwise indicated, data are presented as n (%). NA, not applicable.

TABLE 3 Unadjusted ORs and aORs of ADHD Diagnosis and Medication Use According to Race/ Ethnicity Over 3 Waves

Variable Fifth Grade Seventh Grade 10th Grade

ADHD, diagnosis

White Ref NA Ref

African-American

OR (95% CI) 0.54 (0.43–0.69)*** NA 0.46 (0.36-0.60)***

aOR (95% CI) 0.40 (0.27–0.59)*** NA 0.42 (0.27–0.67)***

Latino

OR (95% CI) 0.21 (0.15–0.30)*** NA 0.18 (0.13–0.26)***

aOR (95% CI) 0.37 (0.22–0.60)*** NA 0.46 (0.26–0.79)**

Other

OR (95% CI) 0.63 (0.38–1.03) NA 0.45 (0.29–0.72)**

aOR (95% CI) 0.76 (0.40–1.41) NA 0.56 (0.30–1.03)

ADHD, medication

White Ref Ref Ref

African-American

OR (95% CI) 0.57 (0.43–0.75)*** 0.58 (0.45–0.75)*** 0.48 (0.35–0.66)***

aOR (95% CI) 0.43 (0.29–0.65)*** 0.41 (0.28–0.62)*** 0.44 (0.28–0.71)**

Latino

OR (95% CI) 0.18 (0.12–0.25)*** 0.21 (0.15–0.29)*** 0.23 (0.17–0.31)***

aOR (95% CI) 0.40 (0.23–0.70)** 0.43 (0.25–0.74)** 0.41 (0.21–0.79)**

Other

OR (95% CI) 0.45 (0.25–0.80)** 0.39 (0.23–0.67)** 0.42 (0.22–0.79)**

aOR (95% CI) 0.60 (0.31–1.18) 0.46 (0.25–0.86)* 0.45 (0.21–0.98)*

Adjusted for child age, sex, health insurance, mental health symptoms, and school functioning; household composition,

income, and highest parental educational attainment; parent English profi ciency and reported receipt of FCC in child’s

health care; and study site. NA, not applicable. * P < .05. ** P < .01. *** P < .001.

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odds of medication use compared

with white children. This sample

limited to children with a diagnosis

did not have adequate numbers to

support adjusted analysis (n = 328 for fifth grade; n = 368 for 10th grade); results not shown in table.

Medication Rates Among Children Without ADHD According to Symptoms or Diagnosis by Fifth Grade

Among children who had neither

past-year symptoms consistent with

ADHD nor an ADHD diagnosis by fifth

grade (and thus would not likely meet

ADHD diagnostic criteria at any age),

there was no statistically significant

difference in past-year medication use

according to race/ethnicity (1%–2%

of white, African-American, and

Latino children were taking ADHD

medication at fifth grade and 2%–3%

at seventh grade). By 10th grade,

the difference in medication use was

statistically significant (P = .004); 7% of white children without ADHD

according to symptoms or diagnosis in

fifth grade took ADHD medication in

the past year, compared with 4% for

African-American children and 3% for

Latino children. In adjusted analyses,

however, the odds of medication use

were not statistically significant for

African-American and Latino children

compared with white children at fifth,

seventh, and 10th grades ( Table 5).

Findings were not sensitive to

inclusion of FCC care as a covariate.

DISCUSSION

In this longitudinal, multisite study,

African-American and Latino

children were less likely to have a

parental report of ever receiving an

ADHD diagnosis or of taking ADHD

medication in the past year compared

with white children; the disparity

in medication use persisted among

children with either a diagnosis of

ADHD or with symptoms of ADHD.

The disparity was not observed in

adjusted analysis among children who

had no history of ADHD according to

diagnosis or symptoms by fifth grade.

Other large studies have found similar

disparities in ADHD diagnosis for

African-American and/or Latino

children, including the 2003–2004 and

2007 National Survey of Children’s

Health, 7, 26, 27 the Early Childhood

Longitudinal Survey–Kindergarten

Cohort, 2, 3 the 1997 to 2001 National

Health Interview Survey, 6 and the 1997

to 2005 Medical Expenditure Panel

survey. 5 Similar disparities have also

been reported in medication use for

ADHD, finding that African-American

and/or Latino children are less likely

to take a medication for ADHD. 1, 3, 5, 6, 27

Reports from 3 waves of the National

Survey of Children’s Health (2003,

2007, and 2011–2012) suggest that

racial/ethnic disparities in diagnosis

and medication treatment continued to

emerge over time, reflecting the trends

of increasing parent-reported ADHD

diagnosis and medication use in the

United States from 2003 to 2011. 1, 27

Not all studies, however, have found

racial/ethnic disparities in ADHD

diagnosis or medication use. 28, 29

For example, Froehlich et al, 29

using 2001–2004 National Health

and Nutrition Examination Survey

data, found no such disparities

among children meeting Diagnostic and Statistical Manual of Mental

6

TABLE 4 aORs of ADHD Medication Use by Race/Ethnicity Over 3 Waves Among Children With a Diagnosis or Symptoms of ADHD

Child Race/Ethnicity Fifth Grade (n = 577) Seventh Grade (n = 721) 10th Grade (n = 645)

% (N) aOR (95% CI) % (N) aOR (95% CI) % (N) aOR (95% CI)

Total 47 (270) 36 (261) 45 (282)

White 73 (125) Ref 61 (118) Ref 67 (143) Ref

African-American 41 (101) 0.33 (0.17–0.62)a 33 (97) 0.34 (0.18–0.64)a 35 (88) 0.41 (0.22–0.75)a

Latino 24 (31) 0.38 (0.16–0.90)a 19 (35) 0.51 (0.23–1.15) 29 (36) 0.42 (0.20–0.86)a

Other 45 (13) 0.37 (0.12–1.10) 29 (11) 0.24 (0.11–0.56)a 44 (15) 0.33 (0.11–0.96)a

Adjusted for child age, sex, health insurance, mental health symptoms, and school functioning; household composition, income, and highest parental educational attainment; parent

English profi ciency and reported receipt of FCC in child’s health care; and study site. Signifi cant fi ndings are bolded. Fifth grade analysis was limited to children with ADHD symptoms or

diagnosis at wave 1. Seventh grade analysis was limited to children with ADHD symptoms or diagnosis at wave 1 or with symptoms at wave 2 (diagnosis not reported at wave 2). Tenth

grade analysis was limited to children with ADHD symptoms or diagnosis at wave 3. a Signifi cant fi ndings.

TABLE 5 aORs of ADHD Medication Use According to Race/Ethnicity Over 3 Waves Among Children With No Diagnosis or Symptoms of ADHD at Wave 1

Child Race/Ethnicity Fifth Grade (n = 3628) Seventh Grade (n = 3628) 10th Grade (n = 3596)

% (N) aOR (95% CI) % (N) aOR (95% CI) % (N) aOR (95% CI)

Total 1 (44) 2 (86) 4 (138)

White 1 (7) Ref 3 (25) Ref 7 (56) Ref

African-American 2 (22) 1.03 (0.27–3.96) 3 (33) 0.73 (0.30–1.74) 4 (39) 0.59 (0.28–1.22)

Latino 1 (13) 0.51 (0.12–2.23) 2 (23) 0.85 (0.31–2.34) 3 (38) 0.55 (0.24–1.29)

Other 1 (2) 1.23 (0.13–11.64) 2 (5) 1.08 (0.30–3.92) 4 (5) 0.70 (0.25–2.02)

Adjusted for child age, sex, health insurance, mental health symptoms, and school functioning; household composition, income, and highest parental educational attainment; parent

English profi ciency and reported receipt of FCC in child’s health care; and study site.

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PEDIATRICS Volume 138 , number 3 , September 2016

Disorders, Fourth Edition, criteria for ADHD. Differences in study

findings may relate to such factors as

relative distribution of white versus

nonwhite participants, or the breadth

of socioeconomic covariates included

in adjusted analyses.

Few previously published studies

have empirically addressed the

question of whether ADHD medication

disparities are primarily due to

underdiagnosis/undertreatment of

African-American and Latino children

or overdiagnosis/overtreatment of

white children. One commentary

addressed the question of

overdiagnosis but without empirical

data. 30 Another study focused on

whether overdiagnosis of ADHD

was a problem, based on previously

published ADHD prevalence data. 8

We found that, among children with a

potential need for ADHD medication

(ie, ADHD symptoms or diagnosis),

African-American and Latino children

were less likely to take ADHD

medication than white children;

however, among children with no

apparent need for ADHD medication

(ie, no ADHD symptoms or diagnosis),

white children were not significantly

more likely to take medication. Our

study does not have an objective

measure of ADHD prevalence, and

thus we are unable to directly address

this question of overdiagnosis and

overtreatment. However, our findings

do indirectly suggest that these

disparities are more likely from the

underdiagnosis/undertreatment of

African-American and Latino children

than the overdiagnosis/overtreatment

of white children. It may be that

African-American and Latino children

are less likely to report taking a

medication for ADHD because they

are less likely to receive a diagnosis

of ADHD, or because when diagnosed,

they are less like to receive (or accept)

a medication for ADHD.

In fifth and seventh grades, only

small percentages of children

with neither symptoms nor a

diagnosis of ADHD by fifth grade

were taking ADHD medication

(across all racial/ethnic groups of

children); the implication of this

finding is that overdiagnosis and

overtreatment likely contribute

only minimally to the disparity

in medication treatment. This

proportion increased for 10th

grade, particularly among white

children, and in unadjusted analysis,

there was a significant difference

between white children compared

with African-American and Latino

children. We found no statistically

significant differences in adjusted

odds, which may be due to the small

number of children with medication

use in those models.

This study has limitations. First,

parent-reported data may introduce

reporting bias; however, a recent

study reported similarities between

parent-reported ADHD estimates and

administrative claims data estimates. 31

In addition, we were unable to include

reports from teachers or schools

on school functioning, which is an

important element of ADHD symptom

reporting. Our child-reported school

functioning measures are limited

in that they focused on behavior,

were not validated against teacher

ratings, and may not accurately reflect

academic achievement. It is also

possible that there are racial/ethnic

differences in parental reporting of

symptoms for which we are not able to

account; these differences in reporting

could potentially lead to either an

underestimation or overestimation

of the disparities in our findings. Data

collection was limited to children in

public school settings in 3 metropolitan

areas, and our sample’s racial/

ethnic composition is different from

the US composition because it was

designed to have a balanced sample of

African-American, Latino, and white

children; thus, caution should be used

in generalizing our findings to other

populations. We also lacked detailed

information on ADHD medication

use (eg, type and dose of medication,

duration of use); these data should be

considered for future studies.

CONCLUSIONS

Our findings have implications for the

diagnosis and treatment of ADHD.

There are various improvements in

care that may help in closing this gap in

diagnosis and treatment. These include

actively and universally eliciting

parental concerns about child behavior

and academic performance (at home

and school) at well-visits, 32, 33 providing

care that is culturally relevant in

families’ preferred languages, 34 and

linking with community resources

to provide mental health education,

guidance, and services to families (eg,

parent training courses for parents of

children with ADHD). 35 – 39 Pediatric

clinicians also may need to consider

universal behavioral health screening

tools for children to improve diagnostic

capabilities and recognize when a

child has ADHD symptoms, even if

the problem is not recognized by the

parent.

Because the rates of diagnosis

and treatment are rising in the

general population of US children, a

significant need remains to identify

and treat African-American and

Latino children who have ADHD and

avoid a widening of these disparities.

ACKNOWLEDGMENTS

We thank the Healthy Passages team,

staff, and participants for making the

study possible.

7

ABBREVIATIONS

aOR:  adjusted odds ratio

ADHD:  attention-deficit/

hyperactivity disorder

CI:  confidence interval

DPS:  Diagnostic Interview

Schedule for Children

Predictive Scales

OR:  odds ratio

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COKER et al

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obtained funding, participated in study design and interpretation of fi ndings, revised manuscript drafts, and contributed to overall supervision; and all authors

provided fi nal approval for the submitted manuscript.

DOI: 10.1542/peds.2016-0407

Accepted for publication Jun 30, 2016

Address correspondence to Tumaini R. Coker, MD, MBA, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 12-436, Los

Angeles, CA 90095. E-mail: tcoker@mednet.ucla.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: The Healthy Passages Study was funded by the Centers for Disease Control and Prevention, Prevention Research Centers (Cooperative Agreements CCU409679, CCU609653, CCU915773, U48DP000046, U48DP000057, U48DP000056, U19DP002663, U19DP002664, and U19DP002665). The fi ndings and conclusions in

this report are those of the authors and do not necessarily represent the offi cial position of the Centers for Disease Control and Prevention.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

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