Disparities in ADHD Assessment, Diagnosis, and Treatment

Abstract

The regional study by Baumgardner and colleagues converges with existing literature to clearly show that the distribution of ADHD diagnosis falls along socioeconomic lines, according to the relative wealth of neighborhoods. This adds additional evidence that trends in the diagnosis and treatment for ADHD in children move in the exact opposite direction from those who are at highest risk for meeting criteria, for experiencing impairment, for and downstream socioeconomic sequelae. Contributing factors, such as marginal diagnoses (such as when parent and teacher symptom reports diverge), inadequate insurance coverage, limited time, and lack of familiarity and comfort with diagnostic and prescribing guidelines, may leave the door open to misdiagnosis and treatment. In some cases, this may take the form of over-diagnosis and over-treatment, in the form of false-positive diagnoses with ADHD, and treatments for it, or may alternatively take the form of false-negative diagnoses. If the social and epidemiological data are any indication, it is furthermore likely that such false-positive or false-negative outcomes may break along socioeconomic lines. Increased use of formal screening tools, increased curricular time for mental health in primary care residencies, support for physicians in the field in the form of referral options and remote consultation and support, may all serve to improve quality of care for individual patients, and may also serve to regularize treatment across socioeconomic and sociodemographic lines, hence reducing disparities. Further research is needed to study the root causes and dynamics that create such disparities, but the steps outlined above may help in the near term.

Full text

INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 40(4) 383-389, 2010
DISPARITIES IN ADHD ASSESSMENT, DIAGNOSIS,
AND TREATMENT*
CHRISTOPHER P. MORLEY, PH.D.
SUNY Upstate Medical University, Syracuse
ABSTRACT
The regional study by Baumgardner and colleagues converges with existing
literature to clearly show that the distribution of ADHD diagnosis falls
along socioeconomic lines, according to the relative wealth of neighborhoods.
This adds additional evidence that trends in the diagnosis and treatment for
ADHD in children move in the exact opposite direction from those who are
at highest risk for meeting criteria, for experiencing impairment, for and
downstream socioeconomic sequelae. Contributing factors, such as marginal
diagnoses (such as when parent and teacher symptom reports diverge),
inadequate insurance coverage, limited time, and lack of familiarity and
comfort with diagnostic and prescribing guidelines, may leave the door
open to misdiagnosis and treatment. In some cases, this may take the form of
over-diagnosis and over-treatment, in the form of false-positive diagnoses
with ADHD, and treatments for it, or may alternatively take the form of
false-negative diagnoses. If the social and epidemiological data are any
indication, it is furthermore likely that such false-positive or false-negative
outcomes may break along socioeconomic lines. Increased use of formal
screening tools, increased curricular time for mental health in primary care
residencies, support for physicians in the field in the form of referral options
and remote consultation and support, may all serve to improve quality of
*The writing of this commentary was partially supported by Health Resources and Services
Administration (HRSA) grant D54HP05462, “Administrative Academic Units” (Andrea T.
Manyon, PI).
383
Ó2010, Baywood Publishing Co., Inc.
doi: 10.2190/PM.40.4.b
http://baywood.com

care for individual patients, and may also serve to regularize treatment
across socioeconomic and sociodemographic lines, hence reducing dispar-
ities. Further research is needed to study the root causes and dynamics that
create such disparities, but the steps outlined above may help in the near term.
(Int’l. J. Psychiatry in Medicine 2010;40:383-389)
Key Words: attention deficit and disruptive behavior disorders, health status disparities,
primary health care
Attention-Deficit/Hyperactivity Disorder (ADHD) is a valid and serious condition
in children [1], with potentially severe and costly downstream issues for the
affected patient, as well as to society when left untreated [2, 3]. However, a
growing number of studies and commentaries note large diagnostic and treatment
disparities between racial and socioeconomic groups [4-10], and also note a far
greater frequency of diagnosis in boys [9]. Although true prevalence rates vary,
a reasonable estimate of the number of children who meet DSM-IV criteria for
ADHD in the United States suggest that roughly 7.8% of the juvenile population
are affected [4]. However, in the same sample, only 47.9% of children who met
criteria had ever been diagnosed with ADHD, and only 32.0% of those meeting
criteria had been treated consistently with medications in the year prior to the
survey. To compound the issue, the presence of apparently “true” ADHD by
formal assessment in the Froelich study was higher in lower socioeconomic
quartiles, but was more frequently diagnosed and treated in the White and
wealthier segments of the sample.
The study by Baumgardner and colleagues [11] converges with the existing
literature in several ways, and does so with a new, novel geographic perspective.
Their regional study clearly shows that the distribution of ADHD diagnosis falls
along socioeconomic lines, according to the relative wealth of neighborhoods;
and furthermore, aligns these regional diagnostic trends with the likelihood of
lead presence in the home, which is a predictor and potential biologic precursor
to ADHD [12, 13]. In short, this study adds additional evidence to an argument
posed previously [6, 7]: that trends in the diagnosis and treatment for ADHD
in children move in the exact opposite direction from those who are at highest
risk for meeting criteria, for experiencing impairment, and for downstream socio-
economic sequelae.
But what are the identifiable sources of such disparities, and how should they
be addressed? Clearly these are very large questions that need untangling,
and one potential place to start is at the initial point of care. While there are
probably no formal estimates of who performs this initial assessment, a likely
pathway is for the first suggestion of ADHD as a diagnosis to come from a
child’s teacher [14]; the first interaction with a medical professional is then
384 / MORLEY

often the child’s primary care provider. Unfortunately, this may be a point at
which the system breaks down.
ADHD IN THE PRIMARY CARE SETTING—
DIFFICULTIES AND CHALLENGES
The American Academy of Pediatrics (AAP) issued guidelines for the diag-
nosis and treatment of ADHD in primary care settings nearly a decade ago
[15-18]. However, Leslie and others have noted that implementation of these
guidelines needs tailoring, depending upon the setting in which they are used
[19], and that a number of issues crop up, such as marginal diagnoses (e.g.,
when parent and teacher symptom reports diverge), insurance plans that don’t
adequately cover treatment, or when there is limited time for family education
and support [20].
Beyond the issue of guideline implementation, a number of studies have
identified limits to knowledge about, or even about the existence of, the AAP
guidelines [21-27]. In part, perhaps due to disciplinary/specialty boundaries,
family physicians have been shown in the past to be less aware of the AAP
guidelines than pediatricians [23]. Additionally, in a sample of New York primary
care physicians who attended a mental health management training series, a
disconcerting level of discomfort with management of ADHD and other mental
health issues was reported by both specialties [27]. In addition to problems
related to familiarity, implementation and comfort with the AAP guidelines,
subtle factors may influence both the family and physician halves of the
doctor-patient dyad. Doubts about the validity of ADHD, of the use of stimulant
medications, or of race-blind treatment, are demonstrably present in African-
American and Latino communities [8, 10, 28-31]. On the provider side, race,
gender, and insurance status have all been shown to have an effect upon
the diagnostic and treatment calls made by physicians as well as by psychologists
[6, 32, 33].
Lack of familiarity with diagnostic guidelines, the difficulty in applying
national, general guidelines to localized and specific contexts (e.g., where referral
is unavailable, the patient uninsured, etc.), when combined with discomfort
in prescribing appropriate medications as well as with the general challenges
presented in primary care practice as illustrated above, may leave the door
open to misdiagnosis and treatment. In some cases, this may take the form of
over-diagnosis and over-treatment, in the form of false-positive diagnoses with
ADHD and treatments for it; or it may alternatively take the form of false-
negative diagnoses. If the social and epidemiological data are any indication,
it is furthermore likely that such false-positive or false-negative outcomes may
break along socioeconomic lines. Baumgardner and colleagues [11] have now
added to the existing evidence that this is the case, and have done so from a
new methodological perspective.
DISPARITIES IN ADHD TREATMENT / 385

ADDRESSING THE ISSUE—NO SMALL TASK
Primary care physicians are on the front lines of ADHD assessment, diagnosis,
and treatment, often whether they want to be or not. In an era of increasing
recognition of childhood psychiatric disorder, an appropriate concomitant
increase and improvement in child mental health services around the United States
is largely absent [34]. With few referral options for formal assessment and
long-term treatment, the primary care physician will remain on the front lines
of ADHD care for the foreseeable future.
And this is not a bad thing. Primary care physicians (both pediatricians and
family physicians) are often very effective in this role, and provide ADHD
treatment in the larger context of the child’s health and lifespan. However,
there are interventions which may improve the quality of assessment, and help
alleviate disparities in diagnosis and treatment of ADHD. For example, Brown
and colleagues recently reported that the use of the Strengths and Difficulties
Questionnaire to screen children for common mental health issues substantially
increased the number of potential issues that would not have been identified
without use of the tool; this effect may be most pronounced among moderate
cases and in African-American and Latino patients [35].
Increasing dedicated curricular time in primary care residencies to ADHD
and other mental health disorders would likely be difficult, given the number of
conditions, skills, and competencies that now compete for such time. However,
increasing support for community physicians by offering enhanced training,
outreach, and telepsychiatry consultation may be effective [27, 36].
Finally, more needs to be known about the sources of disparity in ADHD
diagnosis and treatment. The literature cited here is derived from a variety of
methods and contexts. However, epidemiological, cultural, demographic, geo-
graphic, social, clinical, and ethical commentaries converge—ADHD diagnosis
and treatment is either under-recognized, treated, and diagnosed in poorer
and minority communities, over-diagnosed and treated in more well-off or
less heterogeneous communities, or both. A concerted research effort into the
sources of these disparities, along with enhanced screening, guideline dissem-
ination, training, and remote support may be the best short- to medium-term means
to address the issue.
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Direct reprint requests to:
Christopher P. Morley, Ph.D.
Assistant Professor & Vice Chair for Research
Department of Family Medicine
Assistant Professor of Public Health Department of
Public Health & Preventive Medicine
SUNY Upstate Medical University
750 E. Adams St., Madison-Irving Medical Center Suite 200
Syracuse, NY 13210
e-mail: morleycp@upstate.edu
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