Unconscious Bias and the Diagnosis of Disruptive Behavior Disorders and ADHD in African American and Hispanic Youth.

TLDR: How unconscious bias can lead to diagnostic disparities in the assessment of disruptive behavior disorders and ADHD is reviewed, the implications that these biases can have on ethnic and racial minority youth, and how this challenging clinical topic should be addressed in academic psychiatry are reviewed.

Abstract: Diagnostic evaluation of psychiatric disorders in children and adolescents relies in part on subjective interpretations of information from a clinician. Clinicians must interpret and contextualize information obtained from family, caregivers, and educators in order to assign an appropriate diagnosis. However, environmental and sociocultural influences can make the diagnosis of psychiatric disorders challenging, and appreciating these influences should be a priority in academic psychiatry. This can be particularly true for the provision of a diagnosis of oppositional defiant disorder (ODD), conduct disorder (CD), and attentiondeficit/hyperactivity disorder (ADHD), as diagnosing these complex conditions can be nuanced. There is a growing body of evidence indicating that when compared to non-Hispanic white youth, some ethnic and racial minority youth are more likely to receive a diagnosis of a disruptive behavior disorder and are less likely to receive a diagnosis of ADHD [1–8]. When controlling for confounding variables such as adverse childhood experiences, prior juvenile offenses, genetics, and sociodemographics, these diagnostic and treatment disparities remain [6–8]. Although the cause of these diagnostic disparities is multifactorial, there is concern that unconscious biases may play a role in diagnostic decision-making. As a result of these biases, psychiatrists and trainees may judge and interpret behaviors seen in ODD, CD, and ADHD differently based on race or ethnicity, putting vulnerable populations at risk [5, 9]. Additionally, the current standard of practice is to routinely consider a broad differential of comorbid disorders when youth exhibit disruptive symptoms; however, biases may lead clinicians less likely to explore these potential explanations for behavior [10–12]. When a diagnosis of a disruptive behavior disorder is provided in place of ADHD (or ADHD is not included as a concurrent diagnosis), there are significant clinical implications, as this can limit access to medications, therapy, and other supportive services. This lack of services can put ethnic and racial minority children at risk for perpetuating the disparities which currently exist in the medical, educational, and juvenile justice systems. Recognizing the magnitude of this concern, this commentary reviews how unconscious bias can lead to diagnostic disparities in the assessment of disruptive behavior disorders and ADHD, the implications that these biases can have on ethnic and racial minority youth, and how this challenging clinical topic should be addressed in academic psychiatry.