Kelly Yang: Closing the Disparities in Childhood ADHD Treatment

The COVID-19 pandemic may have exposed more disparities based on race or ethnicity in ADHD care.

There are many disparities in medical care, particularly in psychiatry and attention deficit/hyperactivity disorder (ADHD).

In fact, the COVID-19 pandemic might have shed some light on some of the racial discrepancies prevalent in medicine.

In an interview with HCPLive®, Kelly Yang, a Service and Research Scholar at Albert Einstein College of Medicine, talked about why these discrepancies exist in ADHD care and what can be done in the future to close some of the treatment gaps for patients.

Earlier this year, Yang presented new data on the racial and ethnic disparities in ADHD in early childhood during the annual American Psychiatric Association (APA) virtual conference.

HCPLive: Are these discrepancies potentially worse in psychiatry than they are in other medical spaces?

Yang: I think that mental health disparities are particularly interesting, because there's so much more nuance to why people decide to seek mental health treatment. And there's a lot of literature out there about access to care and the fact that minorities access mental health treatment at much lower rates than white people with mental health conditions.

And there are disparities too in physical health conditions. I believe that within mental health care, the disparities are more significant because it takes an extra step of recognizing that you have a condition that needs to be seen by a mental health professional and bringing it to the attention of the primary care physician.

I also think a lot of minorities might not manifest mental health conditions in the same way that the white majority population does, so they can go under detected. For example, a lot of minorities, particularly immigrants, are more likely to complain of somatic symptoms related to their mental health complaints.

So instead of saying I'm anxious or I'm depressed, they might say I have a stomachache, or I have headache.

That makes it so they are more likely to go to their primary care physician, and then it might not go detected as a mental health condition, and then they might not get the mental health treatment that they need.

There's a lot more nuance to mental health disparities than physical health disparities.

HCPLive: How detrimental is it for ADHD to go unchecked?

Yang: Early intervention is generally associated with the best outcomes later on in life. And there have been studies out there that have shown that the longer you wait to intervene on ADHD symptoms, the worse outcomes are later on life.

It makes sense because if you think about it, if a child is having trouble focusing on school, or having trouble sitting still or getting punished and taken out of classrooms because they're just being disruptive or hyperactive, then it's more likely that they'll miss out on important lessons or like their grades will suffer.

Then that really affects your functioning later on in life with job prospects, social functioning, just numerous areas of functioning are found to be affected by untreated ADHD. So it definitely can have long-term impacts. And I believe there's studies out there too, that even look at adult ADHD and the effects that it has when it goes untreated. It’s definitely an issue that should be addressed early.

HCPLive: How do you close some of these discrepancies we are talking about?

Yang: Yeah, so there's a lot of layers to addressing these kinds of disparities. I think the most important thing is that we have to take systems level adjustments in order to see patients so I think there's a couple different systems at hand versus like the health care system in America and second is the education system.

I think ADHD is particularly complex, because the way that its detected is both through parents and through teacher report or another reporter in a different environment besides the home.

So it's this complex interplay between the education system and pediatricians and parents. So I think in terms of the health care system, it's important to recognize the impacts of systemic racism.

And there's a lack of representation in medical studies of people of color and the mental health workforce is majority white. So we need to diversify our workforce. So there's a lot of issues that I think then trickle down into internalized biases and discrimination that then disproportionately affect people of color.

I think first it's important to expand the mental health workforce to include people who are of more minority backgrounds. So I think like making mentorship and pipeline programs that help support, not just encouraging people of color to go into mental health professions, but also enabling them through like scholarships, or just like making mental health, career paths more accessible is important.

I think that will help increase levels of treatment in all patients, not just patients of color. But that I think that clinicians need to be kind of aware of their own internal biases and their own ways of recognizing symptoms in patience.

Making sure that they're treating all patients with cultural humility and taking individual preferences into account and not like discriminating in any way based on race or background or culture.

HCPLive: Do you believe untreated ADHD was made worse by the COVID-19 pandemic? Also, do you think the pandemic will lead to more parents seeking an ADHD diagnosis for their children?

Yang: It is possible. I think the thing is there's a difference between parents recognizing that their kids have a problem and actually being able to go to a clinician and have it diagnosed.

And I think that kind of brings into question inequities in access, because certain parents while they might recognize that their kids are struggling with school, and maybe they have more than just the average kid’s inability to pay attention, and they actually might have a diagnosable condition. I think the next step naturally would be to take them to their pediatrician or just seek help in some other way.

Then if they're working a 9-5 job or even working night shift or they have a demanding job where they don't have enough time to kind of seek that care, that could be a barrier. Also just limitations on wait times. We saw a huge increase in demand for mental health treatment and mental health treatment for kids during the pandemic.

With the shortage of mental health professionals the wait times are just a huge barrier. Also, fears about the cost of mental health care. Mental health care often is not covered under insurance still.

There's all these barriers to that make it harder for people of color to get the care that they need for their kids.