Racial, Ethnic, and Language Disparities in Early Childhood Developmental/Behavioral Evaluations

The U.S. Department of Health and Human Services has proposed “Increasing the proportion of children with mental health problems who receive treatment” as one of its Healthy People 2020 Objectives. (1) With high rates (2) and increasing prevalence of childhood behavioral and developmental (DB) conditions,(3–6) promptly identifying and treating these disorders is important so that children’s functional outcomes can be maximized. In addition, since long-term treatment of childhood DB conditions is expensive,(7–9) intervention in early childhood has the potential to produce large cost savings. (10) However, as with other areas of child health,(11, 12) racial/ethnic and language disparities exist in the diagnosis and treatment of early childhood DB conditions. For instance, compared to other children, African-American and Latino children are less likely to be diagnosed with an autism spectrum disorder (ASD), and are more likely to be diagnosed at older ages and with more severe symptoms. (13–18) Likewise, African-American and Latino children are less likely to be diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), and are less likely to be treated with a stimulant medication once diagnosed. (19–22) Table 1 summarizes recent peer-reviewed studies of diagnostic disparities in ASD and ADHD, two common early childhood developmental conditions. Similar disparities exist in the areas of overall developmental risk,(23) depression and mental health disorders,(24–26) use of psychotropic medications,(27) and use of mental health services. (28) These racial and ethnic disparities deserve increased attention given recent demographic trends: Census estimates suggest that the U.S. population younger than age 5 is nearly 50% racial/ethnic minority,(29) and some states are now “majority minority” for young children (30) Table 1 Racial and Ethnic Differences in Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) Diagnosis Rates The medical evaluation and treatment of young children at risk for DB disorders is a complex process involving many steps. The process begins when families identify developmental concerns about their children and raise these concerns with health care providers (Figure 1). Alternatively, a medical or other community or educational professional may recognize a concern via direct observation, developmental/behavioral surveillance, or standardized developmental/behavioral or disease-specific screening. Once a concern is identified, the next step is diagnosis and treatment. Whereas some disorders (such as ADHD) can be diagnosed and treated in the primary care setting, in many cases, a child must be referred to a developmental or mental health specialist for diagnosis through further testing and clinical evaluation. In addition, the child may require additional therapeutic services (such as Early Intervention or disorder-specific therapy). (31, 32) Figure 1 Developmental evaluation and referral process In this review article, we examine the screening, referral, and evaluation process for early childhood DB conditions, assessing points in the process where which racial/ethnic and language disparities are known or likely to occur. In addition, this review article contributes to the current base of knowledge by exploring possible reasons for these disparities. First, we examine different parent beliefs about DB problems among minority children. We also address how minority children are cared for in primary and specialty care settings, looking at missed opportunities for identification of concerns and follow-up of abnormal findings. We investigate the performance of developmental and behavioral screening and diagnostic tests among minority children. Finally, we highlight areas for additional research and suggest possible improvements to reduce racial/ethnic and language disparities in DB care.