ADHD May Be More Common Among African Americans Than Assumed

By Linda Carroll

September 10, 2020

(Reuters Health) - Black children and adults in the U.S. may be more likely than the general population to develop ADHD, a new systematic review and meta-analysis suggests.

In a reanalysis of 21 studies, including more than 150,000 Black participants, researchers found that the prevalence of ADHD among African Americans was 14.54%, which is significantly higher than general-population prevalence estimates in previous studies, according to the report published in JAMA Psychiatry.

The prevalence of ADHD in the general population is 10.8%, according to the U.S. Centers for Disease Control and Prevention.

"There is a need to develop culturally appropriate diagnoses for Black communities in a minority context, as well as evidence-based ADHD treatment (especially for children and adolescents)," said the study's lead author Jude Mary Cenat, a professor and director of the Vulnerability, Trauma, Resilience and Culture Research Laboratory in the School of Psychology at the University of Ottawa.

"We cannot continue to assess youth from Black communities with tools that are not culturally appropriate, to give them medication with known side-effects on biased diagnoses," Cenat said in an email. "Therefore, research needs to be conducted to develop culturally appropriate assessment tools and treatments."

The Diagnostic and Statistical Manual-5 states that African Americans are less likely to be diagnosed with ADHD, Cenat notes. "We hope that (this) systematic literature review has made the results clear and will hopefully allow for a change in the next version of the DSM," she said.

To take a closer look at the prevalence of ADHD among African Americans, Cenat and her colleagues scoured the medical literature looking for peer-reviewed studies that had empirical data on the prevalence of ADHD in samples of Black people and were conducted in countries where Black people were considered to be a minority population.

The researchers ultimately settled on 21 studies, containing 24 samples and subsamples, that had all been performed in the U.S. and were published between 1979 and 2019. The studies had a combined sample size of 154,818. Eleven were conducted using various national survey data. Eight studies looked at children aged <1 to 12 years; one examined adolescents aged 13 to 17; 13 included both children and adolescents and two looked at adults aged 18 and older. One sample was of economically fragile families and two were of juvenile offenders.

In a narrative review of the studies in their analysis, Cenat and her colleagues found risk factors for ADHD included age, gender, race, socioeconomic status, familial factors, environmental factors and risk behaviors.

Dr. David Goodman welcomed the new findings.

"This is a great paper," said Dr. Goodman, an assistant professor in the department of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine in Baltimore and a member of the executive board of the American Professional Society for ADHD and Related Disorders.

"It highlights for clinicians that ADHD does exist in the African American community and at a rate equal to that in whites, if not a bit higher," Dr. Goodman said. "The reason this is so important is that untreated ADHD can lead to a tremendous number of negative consequences. It's not just that these individuals can't pay attention and are forgetful."

Those consequences include being less likely than whites to finish high school, being more likely to smoke, being more likely to have a history of unstable employment, being more likely to be involved in criminal activity, being more than twice as likely to be divorced and being 10 times more likely to have pregnancies as adolescents and young adults, Dr. Goodman said.

Dr. Goodman points to bias as the explanation for the lower rates of ADHD diagnosis among African Americans in some earlier studies.

There are biases in three realms that get in the way of African Americans receiving care for ADHD, Dr. Goodman said. "First, the education system for kids: teachers may or may not be biased, but they may fail to bring this to the attention of parents, sometimes because they feel the parents won't be receptive," he said.

Another source of bias can be the school system, Dr. Goodman said. "The educational tester may have bias when testing the children, ascribing deficits to issues other than ADHD."

There can also be a cultural bias, Dr. Goodman said. "The parents may not see their children's behavior as problematic or outside of normal. And if they don't believe in psychiatric disorders, including ADHD, they won't seek care or they will seek alternative care through non-conventional treatments."

SOURCE: JAMA Psychiatry, online September 9, 2020.