Who Gets Diagnosed with ADHD and How?

Approximately 1 in 10 children ages 6 to 17 years old are diagnosed with ADHD.¹ Unfortunately, there is currently no diagnostic test as the authors of this month’s article “Attention-deficit/hyperactivity disorder” point out. As Rajaprakash and Leppert describe in their article (10.1542/pir.2020-000612), the diagnosis of ADHD relies entirely upon clinician assessment. Accurate diagnosis of ADHD is important since overdiagnosis exposes children unnecessarily to medications with potential negative effects on weight and sleep, while underdiagnosis may be even worse for children. Untreated ADHD has been associated with long-term negative outcomes in terms of drug use, employment challenges, obesity, self-esteem, and social function.² Importantly, treatment reduces the adverse impact of ADHD on these outcomes.

As Rajaprakash and Leppert point out, studies have found that a diagnosis of ADHD is less prevalent among children from ethnic/racial minority backgrounds as compared with non-Hispanic White children.^3,4 This is somewhat surprising because markers of socioeconomic deprivation such as exposure to adverse childhood experiences are correlated with both racial/ethnic minority status and ADHD.⁵ A concerning potential explanation for this finding is that Black children compared with white children may be more likely to have symptoms suggestive of ADHD but less likely to receive a diagnosis.⁶ Given the potential negative ramifications of a missed diagnosis, understanding and eliminating the causes of discrepancy in rates of ADHD diagnosis by race and ethnicity is a critical goal for achieving equity in health outcomes.

The discrepancy may be in part due to immutable genetic differences that render some children at greater biological risk of having ADHD than others, as suggested by studies demonstrating ADHD clustering in families.⁷ However, the prevalence of ADHD overall has steadily increased over the last 20 years,¹ indicating that receiving a diagnosis is determined not only by biological factors, but also additional factors that are amenable to change. These factors include teachers’ and parents’ ability to identify telltale signs, parents’ desire and capacity to seek care, and clinicians’ use of best practice recommendations to make accurate diagnoses.

To achieve equity in ADHD management, clinicians should endeavor not only to address cases that present to their practice but also reduce parental barriers to bringing their children in for care. Ways to support parents’ self-efficacy include permitting unscheduled walk-in appointments for ADHD, sending reminders to families about upcoming appointments for school problems, setting up alternative methods for parents to access and return ADHD screening tools including via a patient portal, and creating permission forms for parents to sign allowing bidirectional communication between the school and the practice. These measures reduce the number of parental organizational tasks for a diagnosis to be made, which may be particularly important for parents who are impacted by their own undiagnosed ADHD.

Finally, it is critical that clinicians use structured tools and a standard approach for ADHD diagnosis and management, such as the algorithm suggested by Rajaprakash and Leppert. One retrospective study of charts from 50 practices found that only half of all children with ADHD had screening tools used to make their diagnosis.⁸ Admittedly, there can be challenges to relying on screening tools to diagnosis ADHD, including low clinician comfort with scoring and lack of tool completion by parents and teachers. Nonetheless, use of a validated assessment tool is the most accurate means of diagnosing ADHD, and some of the interventions mentioned in the preceding paragraph can ease the burden of tool submission. Steadfast resolve to diagnose ADHD using assessment tools ensures clinicians treat all children consistently and in accordance with best practice recommendations.

References

1. Centers for Disease Control and Prevention. ADHD throughout the years. Updated September 23, 2021. https://www.cdc.gov/ncbddd/adhd/timeline.html
2. Shaw M, Hodgkins P, Caci H, et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Medicine. 2012;10(1):99. doi:10.1186/1741-7015-10-99
3. 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 Network Open. 2021;4(3):e210321–e210321. doi:10.1001/jamanetworkopen.2021.0321
4. Morgan PL, Staff J, Hillemeier MM, Farkas G, Maczuga S. Racial and ethnic disparities in ADHD diagnosis from kindergarten to eighth grade. Pediatrics. 2013;132(1):85–93. doi:10.1542/peds.2012-2390
5. Brown NM, Brown SN, Briggs RD, Germán M, Belamarich PF, Oyeku SO. Associations between adverse childhood experiences and ADHD diagnosis and severity. Acad Pediatr. 2017;17(4):349–355. doi:10.1016/j.acap.2016.08.013
6. Coker TR, Elliott MN, Toomey SL, et al. Racial and ethnic disparities in ADHD diagnosis and treatment. Pediatrics. 2016;138(3):e20160407. doi:10.1542/peds.2016-0407
7. Faraone SV, Larsson H. Genetics of attention deficit hyperactivity disorder. Molecular Psychiatry. 2019;24(4):562–575. doi:10.1038/s41380-018-0070-0
8. Epstein JN, Kelleher KJ, Baum R, et al. Variability in ADHD care in community-based pediatrics. Pediatrics. 2014;134(6):1136–1143. doi:10.1542/peds.2014-1500