ADHD: Asian American Children Least Likely to Receive Diagnosis, Treatment

What’s happening – Diagnosing and treating ADHD continues to vary greatly by race and ethnicity, with no sign of systemic disparities abating, according to the findings published in Pediatrics by a team at the Mayo Clinic this March. With little national data on the full scope of the problem, a team led by Yu Shi, MD, MPH, looked at insurance claim data for nearly 240,000 children to get a clearer picture of existing disparities (the last follow-up of the US-based cohort was completed in June 2019, with data analyzed through December 2020). Among their findings: 72% of those diagnosed with ADHD were White, and White children were more likely to receive treatment for ADHD than Black or Asian children. Asian children, in particular, were the least likely to receive treatment for ADHD.

While disparities, including comorbidities, were examined among multiple groups, Shi’s findings provided “some evidence that Asian parents brought their children for clinical evaluation for reasons that differed compared with other racial groups…. Asian children were found to have higher rates of speech-language disorder and autism spectrum disorder while White children had more anxiety and adjustment disorders. It is also likely that patients’ concerns about racism play some role in influencing their willingness to approach the health care system.” Ultimately, Shi’s team concluded that “Clinicians should provide racially and culturally sensitive care in the evaluation and treatment of ADHD to ensure all children receive appropriate care.”

The details—Read the full study by Shi et al in JAMA Network Open.

Why it’s complicated – Prior research reveals that it’s not only BIPOC children who are at risk for a missed ADHD diagnosis but that adults of color are also more likely to be undiagnosed and untreated, compared to their White counterparts.

The perspectives —

  • A piece in Attitude for Professionals points out the majority of ADHD research has focused on White patients, emphasizing the need for clinicians to consider racial, cultural, and ethnic differences when evaluating for ADHD.
  • Academic Psychiatry explores the issue of African American and Hispanic youth being misdiagnosed with a disruptive behavior disorder such as oppositional defiant disorder instead of ADHD (or concurrent ADHD), which can prevent them from receiving proper treatment.
  • Transcultural Psychiatry shares the results of a literature review on challenges in providing ADHD care for minority children. The findings reveal that ethnic minority children have a lower likelihood than their nonminority counterparts to be diagnosed and treated for ADHD.

The conversation —

  • @LearningPillars (Pillars of Learning, neuropsychological testing) tweets: “The original article omitted how racial disparities in oppositional defiant disorder (ODD) vs ADHD diagnosis exist. ODD and conduct disorder get more robust discipline responses than ADHD, and it’s important to see the implications of that….”
  • @PaulJRosen ( of RACER Lab for ADHD research) says: “Racial disparities in school discipline are a huge problem. Black kids are more likely to be suspended than White kids *for the same behavior* Black kids w/#ADHD symptoms less likely to be diagnosed & more likely to be labeled as ‘behavior problems.’ Systemic racism starts early.”
  • @PaulMorganPhD (Center for Educational Disparities Research, Penn State) shares: “Although our focus was on racial/ethnic disparities in diagnosis, we similarly found that school-aged boys were much more likely to have an ADHD diagnosis than girls including conditional on direct measures of achievement, behavior, SES, and other factors.” 

In practice—This series delves into how clinicians can weigh external factors, such as cultural and family values, to help assess ADHD in children from different backgrounds and to deliver a diagnosis to parents. See also our Psy-Q below on talking to families of Asian descent about ADHD.

Psy-Q: This Week's Challenge

How can clinicians better approach conversations about ADHD with Asian American families? Clarice Fangzhou Hassan, LCSW, answers.

Get the Answer

Why Exposure Therapy Works for PTSD, Trauma

What’s happening – When treating patients with PTSD and other types of trauma, psychotherapy – specifically exposure therapy – is considered the most effective modality. But the mechanisms behind why this approach works have largely been unclear, until now. A team working across academic centers in the US used fMRI as part of a small RCT (n = 66) to better understand exactly how this type of psychotherapy impacts the brain. They discovered that psychotherapy creates stronger connections in key areas of the brain that are able to reduce PTSD symptoms. These findings may lead to better treatment options for people who have suffered trauma.

The details – Read the full study by Fonzo et al in Biological Psychiatry.

Why it’s complicated – While psychotherapy is often the treatment of choice for people with PTSD, the current shortage of qualified therapists to deliver treatment can make it difficult for patients to access this option. One solution may be teletherapy sessions, according to a review in Cochrane.

The perspectives – 

  • A meta-analysis in JAMA Psychiatry shows that psychotherapy, pharmacology, and combined treatments for PTSD lead to similar results; however, in the long-term, the results of psychotherapy and combined treatments were more effective than medication alone.
  • A study in Nature reveals that as many as half of patients with post-traumatic stress actually do not respond to psychotherapy. The researchers mapped the response in the brain to understand the connectivity that may characterize a positive treatment response.
  • Psychotherapy and Psychosomatics reports on a study that successfully used computerized cognitive training (cognitive bias modification for appraisals or CBM-APP), along with psychotherapy, to reduce PTSD symptoms.

The conservation –

  • @StandfordPSY (Stanford Psychiatry) tweeted about Fonzo’s study, noting: “According to @StanfordPSYresearchers with colleagues from @UTAustinn, @Penn, @StanfordBrain, @EmoryUniversity & @VAPaloAlot, #PTSD psychotherapy adaptively attenuates functional interactions between frontoparietal & limbic brain circuitry at rest.”
  • @domesticshelter (resource for domestic violence info) says: “Only about 40% of people with PTSD find relief from current treatments which typically involve a combination of psychotherapy and medication.”

In practice –  Trauma-informed care can help provide trauma survivors with a safe space to undergo effective treatment. See our new primer for clinicians. Therapists are at risk of experiencing vicarious trauma, especially during COVID-19 – learn how to protect yourself by accessing valuable supports and resources.

The Complex Relationship Between the Criminal Justice System and Mental Health Services

What’s happening— An international group of researchers (Zhong et al) recently reported that people in prison are at increased risk of committing suicide. The team identified a handful of risk factors associated with suicide, including psychiatric diagnosis, suicidal ideation, and occupying a single cell. To reduce suicide attempts, the experts recommend making a concerted effort to target these risk factors with preventive interventions and to appropriately ensure access to behavioral health services. These findings have brought related studies on the criminal justice system and mental health services back into scope.

For instance, a team at UNC Chapel Hill (Domino et al) shared findings in 2019 that receiving mental health services may actually increase the risk of a person in the criminal justice system being re-incarcerated due to technical violations in the first year they are released back to society. Data was based on just over 3,000 individuals with serious mental illness (SMI) who had been released from prison.

A separate literature review (Lamberti et al) published in 2020 found a correlation between psychotic and manic symptoms and arrest/incarceration. The research revealed that treating mental illness with medication reduces the odds of criminal recidivism. However, the findings also suggested that it’s important to treat a range of factors (not just mania and psychosis) in individuals with mental illness in the criminal justice system to reduce their odds of being rearrested.

The details—Read the suicide study by Zhong et al in Lancet Public Health. Read the re-incarceration study by Domino et al in Health Service Research. Read the literature review by Lamberti et al in Harvard Review of Psychiatry.

Why it’s complicated – Domino’s team points out that the association between receiving mental health services and increased risk of re-incarceration for people with SMI calls attention to the complex relationship that exists between the mental health and criminal justice system. The researchers note the need to delve further into more effective ways to protect this vulnerable group.

At the same time, with a growing number of cities and states legalizing cannabis (as well as psychedelic substances), some experts worry that the mental health effects of increased use, including psychosis and schizophrenia spectrum disorders, may be downplayed and potentially lead to more criminalization.

Programs across the US are being established to better tackle these issues but it will take time to see results. For example

  • New York City launched a test program that will send mental health workers instead of police officers to respond to 911 calls for mental health crises in an attempt to de-escalate situations and avoid incarceration. NBC News talks about the program.
  • The Altamont Enterprise Regional reports on a pilot program, the Albany Alternative Treatment Court, which will divert people in the criminal justice system with mental illness to receive treatment instead of jail time. This effort is based on a similar program in Brooklyn that has been very effective.

The conversation —

  • @HCSO_MHU (Mental Health & Jail Diversion) tweets: “Implementation of proactive trainings like our #mentalhealth CIT class & our @PoliceForum ICIAT class & our @PoliceForum ICAT class enhances the safety of our officers @ our community.”
  • @PewStates (Pew Trusts) says: “In Florida, diverting those facing mental health crises away from jail and into treatment is paying off: Fewer police shootings; Lower recidivism; Millions in taxpayer savings; Smaller jail populations”
  • See also, the US DOJ’s blueprint for reducing recidivism – including by providing substance abuse and mental health treatment for everyone in the criminal justice system who needs access to these services.
  • @ACLU tweets, “People in mental health crises should be met with mental health providers and community supports, not police.”

In practice – See how just-passed (March 11, 2021) American Rescue Plan aims to improve mental health care across the country with federal funding for mobile crisis response teams, the 988 hotline, improved mental health services in schools, and education and training programs to grow the mental health workforce.

 

Last Updated: Apr 20, 2021