ADHD Diagnosis Rates Lower Among Children of Immigrants: U.S. Study

September 26, 2023

Children of immigrant parents are less likely to be diagnosed with ADHD, according to a U.S. nationwide study published in the Journal of Attention Disorders,¹  which found the ADHD diagnosis rate was lower for children with one or more immigrant caregivers than it was for children with U.S.-born caregivers.

Using data from the National Survey of Children’s Health (NSCH), 109,881 children aged 3 to 17 were assigned to one of three groups based on caregiver nativity: U.S.-born (71.94%), non-U.S.-born (18.99%), or both (9.07%).

The more time foreign-born caregivers spent in the U.S., the more likely their child was to receive an ADHD diagnosis. This association was most significant after 30 years in the country. Children with U.S.-born caregivers were the most likely to receive an ADHD diagnosis.

Barriers to Diagnosis and Treatment

ADHD remains one of the most common neurodevelopmental conditions diagnosed in the U.S. Between 9.4% and 9.8% of American children have an ADHD diagnosis, according to data collected by the Centers for Disease Control (CDC) and cited by the researchers.² U.S. prevalence rates are higher than the global average; an estimated 7.6% of children and 5.6% of teenagers have ADHD diagnoses worldwide, the researchers said.

Yet, of the 10 conditions included in the study, ADHD was among the least diagnosed for children of immigrant caregiver(s).

Foreign-born caregivers may face “substantial difficulties in interpreting their child’s behavior according to new social and cultural norms,” and have “different perceptions of what is considered to be typical or developmentally appropriate,” the researchers said.

These children were also less likely to have received medical care in the past year or possess adequate medical insurance. They were less likely to be White, had lower household income, and had lower parental education levels than did children of U.S.-born caregivers.

Diagnostic manuals like the United States’ DSM-V and the World Health Organization’s ICD-11 have previously differed in their definition of ADHD. Though more similar now than in earlier versions, their definitions of ADHD still don’t fully align on symptom composition and criteria — causing ambiguity across countries and cultures.³

“Additionally, the current [U.S.] ADHD identification methodology, which is heavily reliant upon White middle-class reference groups, standard questionnaires, and clinical observations, might not account for the process of acculturation, placing children of minority groups at a disadvantage,” the researchers said.

Parental nativity also influenced treatment outcomes, the study found. Children with foreign-born caregivers (exclusively) were less likely to receive ADHD medication following a diagnosis. No significant differences were found for behavioral interventions. Combining both medication and behavioral therapy has been shown to produce better treatment results than medication alone.^{4, 5}

Future Research

The importance of ADHD care was underscored by the research team, which noted that associated learning challenges, socialization issues, and comorbid diagnoses often worsen if ADHD is left untreated.

“As the share of U.S. immigrants in the population is projected to continue growing, these findings potentially reaffirm a structural lack of medical and behavioral health access in immigrant communities and the difficulties they face in obtaining adequate medical services,” the researchers said.

“The findings of this study indicate a pressing need for more medical attention from the pediatric community toward the population of children with non-U.S.-born caregivers.”

This is the first large-scale effort to measure the association between migration status and ADHD diagnosis rates in the U.S. It contradicts a study conducted in Finland and cited by the researchers, which found increased ADHD diagnoses among children of immigrant parents.⁶

Strategies for Clinicians

In a recent ADDitude webinar on ADHD in communities of color, Cheryl Hamilton, Ed.D., identified strategies to help improve care and treatment. The following G.R.O.W. checklist can help clinicians improve diagnosis and treatment of ADHD among patients with different backgrounds:

• Gain an understanding. “You have to understand the history of ADHD; you have to understand the history of the client; and you have to understand their support system. For African Americans, the support system looks totally different. It’s not just immediate family who are making decisions….”
• Recognize bias and myths. “We’ve got to recognize the need for multicultural training; recognize the need for self-assessment; and then recognize the need for psychoeducation.”
• Operate differently. “What worked for others may not work for this community right here. We want to make sure that we utilize different culturally sensitive assessments… We want to create different treatment plans that, from a holistic perspective, provide different strategies. Operating differently creates a higher level of thinking and a higher level of awareness where you have to go out and collaborate with others.”
• Work within your scope. “We want to want to work within our scope of services; work through an integrative model; work with others through consultation. If that’s not possible, we want to refer.”

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