Identification of ADHD and Comorbid Disorders in Children: The potential role of minority group membership

Identification of ADHD and Comorbid Disorders in Children: The potential role of minority group membership by Rachel Tayler, MSc, MA Advisor: Sarah O’Neill, PhD Attention-Deficit/Hyperactivity Disorder (ADHD) affects six million US children. Females, Latinx, and possibly Black children have lower rates of diagnosis than their Male and White non-Latinx peers. ADHD is behaviorally defined, and as such, clinicians\u27 perceptions of symptoms and determination of diagnoses may be influenced by demographic factors such as race, ethnicity and sex. This vignette study examined whether clinicians\u27 implicit ethnic, racial, and sex biases affect diagnosis of ADHD and comorbid conditions. Psychiatry trainees and pediatricians practicing in the Northeastern U.S. reviewed two vignettes, one that was representative of a Hyperactive/Impulsive presentation of ADHD and common co-morbid externalizing disorders, and a second that was representative of an Inattentive presentation of ADHD and common co-morbid internalizing disorders, and provided the most likely DSM-5 diagnosis for each child. The vignettes were identical except for the child’s race/ethnicity and sex. To assess the study design, and the strength and efficacy of the manipulation, a pilot study was conducted with psychiatry trainees before being carried out with pediatricians. Fifty psychiatry trainees, and 91 pediatricians completed the vignette-based study online. Both samples completed a demographics questionnaire and the vignette portion of the study. Binary logistic regression analyses were used to assess accuracy of ADHD diagnosis based on vignette characteristics such as child sex, child race/ethnicity, and the interaction of child’s sex and race/ethnicity. Non-parametric tests were used to analyze the non-normally distributed variables such as participants’ confidence in the diagnosis provided. The study also explored clinician characteristics, and the possible association between those and diagnostic accuracy. Finally, the study explored diagnostic consistency, and whether common co-morbid diagnoses were diagnosed based on child characteristics. In both studies, no statistically significant impact of child sex, child race/ethnicity, or the interaction of child’s sex and race/ethnicity on the accuracy of diagnosis of both presentations of ADHD was observed. However, overall, rate of accurate diagnosis of ADHD Inattentive presentation was low amongst both samples, with pediatricians providing an accurate diagnosis in only 22% of cases. While limited by sample size, post hoc analyses suggested that pediatricians were mostly likely to inaccurately diagnose ADHD, Predominantly Inattentive presentation in Black boys. Practitioners diagnosing ADHD in children must pay attention to the heterogeneous nature of the pathology to avoid either under, or mis-diagnosing the disorder. Additional research is needed to further investigate implicit bias in the diagnostic process, and how to better diagnostic accuracy for the Predominantly Inattentive presentation of ADHD