SAN FRANCISCO – A very low prevalence of childhood attention-deficit/hyperactivity disorder in New York's Chinatown seems to be attributable to underdiagnosis of the disorder, Dr. Loretta Au said at a poster presentation at the annual meeting of the American Academy of Pediatrics.
Surveys of 225 Chinese immigrant parents, 178 school faculty (mostly teachers), and 20 community-based pediatricians found that parents lacked knowledge about ADHD, and school staff and physicians reported a wide variety of obstacles to diagnosis and management of ADHD in the Chinatown population, reported Dr. Au of the Charles B. Wang Community Health Center, New York, and her associates.
The investigators designed the study after noticing that the 0.1%–0.2% prevalence rate for childhood ADHD at the center was far below reported prevalence rates of 4%–12% for broader populations. Faculty at five Chinatown elementary schools reported that 8% of 3,039 children in the schools exhibited signs of ADHD–a rate consistent with the wider prevalence rates for ADHD–but only 1% of students had official diagnoses for the disorder, the school survey found.
Among 20 pediatricians who returned anonymous, mailed surveys, 70% said they are aware of criteria and guidelines for diagnosing ADHD, and 95% said they would like more help in diagnosing the disorder. A majority of the pediatricians (65%) referred patients with suspected ADHD to neurologists or mental health providers for official diagnosis. Not handling ADHD in the patients' medical home may contribute to underdiagnosis, Dr. Au suggested.
Surveys that were translated into Chinese were answered by parents at schools and the Community Health Center. Only 15% knew of the symptoms of ADHD, and 33% knew about the consequences of untreated ADHD, although 58% of parents had heard of the disorder. Seventy-seven percent were interested in learning more, and 83% said their community needs more information on ADHD.
Common obstacles to diagnosis and management of ADHD reported by physicians were a lack of coordinated care (21%), parental mistrust or denial of the diagnosis (20%), and lack of bilingual mental health services (20%). School faculty also pointed to a lack of coordinated care (18%), a lack of resources (17%), and families who don't follow through on recommendations for evaluation or treatment of ADHD (23%).
“Especially for Chinese patients, and I think in general for Asian patients, ADHD is something that they might have heard about, but they might not think about as a medical problem,” Dr. Au said. “They might not present the problem to their doctor unless asked [about it]. They might be ashamed about the fact that their child is not doing well in school. A lot of times they are concerned about hyperactivity symptoms, but they might blame themselves for poor parenting.”
Busy pediatricians might not pursue the topic if parents don't ask about it, she added. In Chinese immigrant populations, “the pediatrician needs to be asking about school performance, and telling parents about ADHD, and that it might impact upon school performance and the future of the child.”
The results of the study prompted her center to take several steps to increase education and coordination of care around ADHD. The center staff created bilingual educational materials for parents and translated ADHD assessment scales into Chinese. An ADHD multidisciplinary team meets monthly on care management.
A pediatrician and social worker from the center give bilingual workshops in the community and schools about ADHD. Clinicians meet quarterly with school counselors, who now fax referrals to the center for children with ADHD symptoms. The center also started a support group for parents of children with ADHD.