Parental Birth Outside the United States as a Predictor of ADHD Diagnosis in Children

Background: Children of immigrants face unique challenges due to environmental, cultural, and physical factors that may adversely impact their development. Immigration-related linguistic isolation, parental education and employment, socioeconomic status, and cultural attitudes are known to result in differing educational and health outcomes. The CDC reported that Attention-Deficit/Hyperactivity Disorder (ADHD) affects ~10% of United States (US) children, but the condition is often underdiagnosed and undertreated. The extent to which immigration-related challenges may adversely affect early diagnosis and treatment of ADHD is unknown. This study uses a nationally representative sample to examine associations between parental birth outside the US and ADHD diagnosis in children.

Methods: Secondary analysis of a combined 2016-2019 National Survey of Children’s Health (NSCH) dataset was completed using logistic regression models. The predictor variable was parental birth outside of the US with the response variable being rates of ADHD, Autism Spectrum Disorder (ASD), diabetes, asthma, and heart conditions in children aged 3-17. The reference group included children with US-born parents. Adjusted Odds Ratio (aOR) and P-values were computed, adjusted for the child’s age, race, household income, highest level of education of adults in the household, insurance coverage, and primary language spoken in the household.

Results: Among the five conditions considered for the analysis, children with ADHD were the least likely to come from a household with both parents being born outside of the United States (aOR=0.341, p-value <0.001) (Figure 2). The odds ratio increases with one (aOR=0.452, p-value <0.001) and two parents (aOR=0.452, p-value <0.001) being born in the United States, respectively. Notably, the trend holds for all other conditions studied in this analysis.

Conclusion: Parental birth outside the US was found to be a strong predictor of reduced rates of ADHD diagnosis in children. Although lower rates of diagnosis for the other studied conditions were all strongly predicted by parental birth outside the US, ADHD had the lowest likelihood of diagnosis, even after adjustment. Therefore, ADHD diagnosis in children of immigrants is of special concern. Language/educational barriers, cultural attitudes, and access to medical resources should be considered when identifying potential ADHD presentation. Use of rating scales should also be evaluated for utility/robustness/cultural relevance in diagnosing children of immigrants. Pediatricians should be aware that immigration-related challenges can preclude proper diagnosis of ADHD and employ early interventions in these communities. Proper identification and treatment of behavioral challenges in children of immigrants is needed to ensure healthy development.