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States. As noted in our article, there may be significant risk       status of conduct disorder, this reveals important differences
factors for violent behavior that are truly universal.               in our attitudes toward personal responsibility and treatabil-
                                                                     ity in different ethnic groups: in short, that black is bad and
                                        DAVID W. BROOK, M.D.
                                                                     white is mad.
                                       JUDITH S. BROOK, ED.D.
                                           ZOHN ROSEN, M.S.          References
                                     MARIO DE LA ROSA, PH.D.
                                                                       1. Olfson M, Gameroff MJ, Marcus SC, Jensen PS: National trends
                               IVAN D. MONTOYA, M.D., M.P.H.
                                                                          in the treatment of attention deficit hyperactivity disorder. Am
                                    MARTIN WHITEMAN, PH.D.                J Psychiatry 2003; 160:1071–1077
                                               New York, N.Y.
                                                                       2. Meltzer H, Gatward R, Goodman R, Ford T: The Mental Health
                                                                          of Children and Adolescents in Great Britain. London, the Sta-
Ethnic Differences in ADHD                                                tionery Office, 2000.
and the Mad/Bad Debate
                                                                                                ROB EVANS, M.B., CH.B., M.R.C.PSYCH.
TO THE EDITOR: Mark Olfson, M.D., M.P.H., et al. (1) found that                                        Solihull, West Midlands, U.K.
treatment rates for attention deficit hyperactivity disorder
(ADHD) in the United States were lower for black children
than for white children (1.7% versus 4.4% in 1997). Of interest,     Dr. Olfson and Colleagues Reply
in the United Kingdom, a nationwide epidemiological study
                                                                     TO THE EDITOR: Dr. Evans suggests that mental health profes-
found a lower prevalence of ADHD in black than white chil-
                                                                     sionals in the United States and United Kingdom favor diag-
dren (0.4% versus 1.6%) (2). Despite differences in methods,
                                                                     nosing white children with ADHD and black children with
both studies show similar variations across ethnic groups.
                                                                     conduct disorder. To support this assertion, he cites our re-
   One possibility is that such differences reflect financial ine-   cent finding of a higher rate of treatment of ADHD in white
qualities, e.g., that poorer black families in both countries are    than black youth in the United States and a British epidemio-
unable to afford or access services so that black children are       logical study that reported a statistically nonsignificant
underdiagnosed and undertreated. According to this hypoth-           higher rate of conduct disorder in black than white children.
esis, one would expect a low prevalence and treatment rate           The British study also found that across all ethnic groups,
for children in low-income families as well as for black chil-       conduct disorders were highly comorbid with ADHD, with an
dren. This is unlikely for several reasons. First, in the United     odds ratio of 38.43 (95% confidence interval=26.87–54.96).
Kingdom, ADHD is more prevalent in children of low-income            However, bias in routine diagnostic practices cannot be es-
families but less prevalent among black children. Second, the        tablished by analyzing patterns in community prevalence or
significant increase in the rate of treatment for low-income         treatment rates. Such diagnostic biases can be measured only
families in the United States has not been matched by a corre-       by studying the behavior of mental health professionals in re-
sponding increase in treatment rates for black children.             lation to a criterion standard.
Third, difficulties accessing services should not have affected
                                                                        The possibility of widespread ethnic bias in routine clinical
diagnoses in the British study, which involved interviews with
                                                                     diagnostic practice merits careful scientific study. Such re-
children and parents and mailed questionnaires for teachers,
                                                                     search might involve comparisons of ethnically sensitive in-
regardless of whether they had had any contact with services.
                                                                     dependent expert diagnostic assessments (1) with clinical di-
   Dr. Olfson et al. rightly suggest that cultural factors may ex-   agnoses in routine care or sampling the diagnostic judgments
plain the ethnic variation without exploring the possibilities
                                                                     of mental health professionals with standardized clinical pa-
in detail (1). Could misdiagnosis account for the differences?
                                                                     tients or vignettes that systematically vary patient ethnicity
In the absence of laboratory investigations, ADHD remains a
                                                                     (2). In the absence of such research, the politically charged
clinical diagnosis. In clinical practice as well as epidemiologi-
                                                                     speculation offered by Dr. Evans runs the risk of trivializing
cal studies, rating scales are commonly employed to aid diag-
                                                                     what may be an important issue in the delivery of child men-
nosis. Such scales rely on value judgments by respondents,
                                                                     tal health services.
usually teachers and parents, as to whether a child is felt to be
excessively impulsive, inattentive, etc., compared to other          References
children of the same developmental stage or cultural group.            1. Samuel VJ, Biederman J, Faraone SV, George P, Mick E, Thornell
These scales carry the reassuring air of scientific objectivity,          A, Curtis S, Taylor A, Brome D: Clinical characteristics of atten-
but overreliance on their results leads to value judgments be-            tion deficit hyperactivity disorder in African American children.
ing treated as statements of fact.                                        Am J Psychiatry 1998; 155:696–698
  Following this hypothesis, one might conclude that physi-            2. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh
cians, teachers, and families show a more enlightened toler-              BJ, Dube R, Taleghani CK, Burke JE, Williams S, Eisenberg JM, Es-
ance of behavioral disturbance in black children, who are                 carce JJ: The effect of race and sex on physicians’ recommen-
thus spared an inappropriate label of ADHD. Sadly, the British            dations for cardiac catheterization. N Engl J Med 1999; 340:
data do not support such a hypothesis. The overall rate of
mental disorder in black children was higher than in any                                                   MARK OLFSON, M.D., M.P.H.
other ethnic group, with conduct disorder making the biggest                                                MARC J. GAMEROFF, P H.D.
contribution to the difference (2). Are we therefore more likely                                               PETER S. JENSEN, M.D.
to attribute behavioral disturbances to ADHD in whites and                                                  STEVEN C. MARCUS, PH.D.
to conduct disorder in blacks? Given the less-certain illness                                                         New York, N.Y.

932                                                          Am J Psychiatry 161:5, May 2004

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