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Original Investigation
September 9, 2020

Prevalence and Risk Factors Associated With Attention-Deficit/Hyperactivity Disorder Among US Black Individuals: A Systematic Review and Meta-analysis

Author Affiliations
  • 1School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
  • 2Department of Nursing, Université du Québec en Outaouais, Gatineau, Quebec, Canada
  • 3The Library of the University of Ottawa, Ottawa, Ontario, Canada
JAMA Psychiatry. Published online September 9, 2020. doi:10.1001/jamapsychiatry.2020.2788
Key Points

Question  What are the prevalence and risk factors associated with attention-deficit/hyperactivity disorder (ADHD) among US Black individuals?

Findings  This systematic review and meta-analysis assessing the results of 21 studies found that the pooled prevalence of ADHD among 154 818 US Black individuals was approximately 15% and suggested that the associated risk factors included sociodemographic characteristics (age, sex, race, socioeconomic status), risk behaviors, and familial and environmental factors.

Meaning  The higher prevalence of ADHD observed in this study among US Black individuals highlights the need to increase assessment, accurate diagnoses, and culturally appropriate care.

Abstract

Importance  As stated in the DSM-5, it is generally reported that the prevalence of attention-deficit/hyperactivity disorder (ADHD) is lower among Black individuals compared with the general population. However, Black individuals living in countries where they are considered a minority population group (eg, in Northern America and Europe) are underrepresented in studies evaluating ADHD.

Objective  To estimate the pooled prevalence of ADHD and identify associated risk factors among US Black individuals.

Data Sources  This systematic review and meta-analysis identified peer-reviewed studies published until October 18, 2019, using the APA PsycInfo, MEDLINE, Embase, Cochrane CENTRAL, CINAHL, ERIC, and Education Source databases.

Study Selection  Eligible trials were published in French or English, had empirical data on the prevalence of ADHD in samples or subsamples of Black people, and were conducted in countries with Black minority populations. All studies were assessed and passed quality evaluation.

Data Extraction and Synthesis  The PRISMA guideline was used for extracting and reporting data. Random-effects meta-analyses were generated to estimate the prevalence of ADHD among Black individuals using the metafor package in R.

Main Outcomes and Measures  Prevalence and risk factors associated with ADHD among Black individuals were identified.

Results  A total of 24 independent samples and subsamples from 21 studies published between 1979 and 2020 (154 818 Black participants) were included in this systematic review and meta-analysis. All included studies were conducted in the US. Two studies were conducted assessing adults (aged 18 years or older), 8 assessing children (0-12 years), 1 assessing adolescents (aged 13-17 years), and 13 assessing both children and adolescents. The pooled prevalence of ADHD was 14.54% (95% CI, 10.64%-19.56%). In a narrative review of the studies in this analysis, some studies found risk factors associated with ADHD, such as sociodemographic characteristics (age, sex, race, and socioeconomic status), familial factors, environmental factors, and risk behaviors, but the data did not permit a moderation analysis to assess these findings in this study.

Conclusions and Relevance  Contrary to what is stated in the DSM-5, the results of this systematic review and meta-analysis suggest that Black individuals are at higher risk for ADHD diagnoses than the general US population. These results highlight a need to increase ADHD assessment and monitoring among Black individuals from different social backgrounds. They also higlight the importance of establishing accurate diagnoses and culturally appropriate care.

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    2 Comments for this article
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    disability
    Darryl Wisher, BS Pharm | mega aid pharmacy
    Like all other d/s ADHD varies in the clinical manifestation of its severity. one shouldn't use this or any other study as a means of subclassification of impaired intelligence for this patient population as has so often been done in the past. I speak as one intimately familiar with same. Does it result in impaired performance? - yes I must admit but simultaneously I advocate for a more global definition as advocated in the Steinberg theory of intelligence put forth close to 4 decades hence. too many times such studies have been postulated to demonstrate the premise of inferior intelligence among the Black populace. I hope this is not yet such another one as the premise is simply not true. The use of medications[controlled and uncontrolled] along with cognitive behaviour training has proven to be of great benefit in this same population and I should sincerely hope that there is a follow up study along that line of thought lest this be indeed another study of derogatory confirmation bias perpetuating the multitudes of such which preceded it
    CONFLICT OF INTEREST: None Reported
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    ADHD Prevalence among Black Individuals: More Explorations Are Needed
    Wang Shunan, MD. | Beijing University of Chinese Medicine
    Cenat et al systematically reviewed and meta-analyzed the prevalence of attention-deficit/hyperactivity disorder (ADHD) and its associated risk factors among US Black individuals, by showing that ADHD was more common in Black individuals than the general population. The findings of this study are overturning the traditional claims of the DSM-5, and emphasize the need of informing healthcare practitioners to increase monitoring efforts of ADHD assessment among Black individuals. We here raise two points of concern related to the methodological aspects of this systematic review and meta-analysis.
    Firstly, overall investigation of 21 studies revealed that pooled prevalence estimate of ADHD was obsessed
    by strong evidence of between-study heterogeneity, with the inconsistence index reaching as high as 99.76%, which might be driven by the extremely high prevalence of ADHD at 58% in the study by Bussing et al. It is premature and risky to draw a conclusion in the presence of wide disparities across studies. Further explorations on the sources of heterogeneity by means of subsidiary analyses and meta-regression models are warranted.
    Secondly, it is widely accepted that at the core of a meta-analysis is the proper handling of publication bias, which is an important cause of incorrect conclusions in systematic review and meta-analysis. In this study, the authors adopted the Kendall τ rank-order correlation method to assess the probability of publication bias. In fact, selection bias is indeed an issue for this study, as search results were limited to articles published in French or English. More valid methodologies, such as the Begg’s funnel plot, Egger’s regression asymmetry test, and trim-and-fill analysis are encouraged to provide a more accurate and reliable answer to the prevalence and risk factors of ADHD under consideration.
    Despite above two points of methodological concern, we believe that the systematic review and meta-analysis by Cenat et al1 issues an international call for the strengthened coordination of surveillance efforts on ADHD among Black individuals.

    We declare no competing interests.
    CONFLICT OF INTEREST: None Reported
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