Racial and Gender Disparities in Community Mental Health Center Diagnoses of Adolescent ADHD and Comorbidities: A Mixed Methods Investigation

Though ADHD is the most common pediatric diagnosis in community mental health clinics (CMHCs), little is known about its diagnostic accuracy in these settings. We characterize CMHC diagnostic patterns for ADHD and common comorbidities with attention to gender and racial/ethnic disparities and the impact of misdiagnosis on evidence-based treatment implementation. Culturally diverse adolescents with a primary diagnosis of ADHD ( N= 278) completed comprehensive research team diagnostic assessments. Concurrently, they were assessed at one of four CMHCs in a large United States city. CMHC psychiatric diagnoses were obtained from electronic health records and compared to best practices research diagnoses. Mixed methods analyses characterized diagnostic agreement, racial/ethnic and gender disparities, and the effect of missed ADHD diagnoses on treatment implementation, as well as agency staff perceptions of barriers and facilitators to accurate diagnosis. Diagnostic agreement was unacceptable for all diagnoses ( k= .02 to .19). CMHCs provided an ADHD diagnosis to 65.4% of best practices diagnosed participants. Female gender and White race were associated with missed ADHD diagnoses (often in favor of depressive or adjustment disorders) and CMHCs demonstrated overdiagnosis of conduct disorder (CD) in African American youth. Missed ADHD diagnoses predicted clinician deviation from evidence-based treatment for ADHD. Agency stakeholders noted systemic barriers and clinician beliefs and biases that may contribute to diagnostic inaccuracy and made suggestions for future practice. CMHCs might review their ADHD diagnostic practices to identify contributors to misdiagnosis, such as racial and gender biases, clinician inexperience, and systemic disincentives for careful diagnosis. Adopting systematic diagnostic practices such as pursuing parent and teacher ratings, consulting the DSM when diagnosing, and integrating supervisors into diagnostic process may be helpful.