Over the last decade, Attention Deficit Hyperactivity Disorder (ADHD) has become a prevalent diagnosis and has become part of the mainstream culture in school age children (5 years of age to 18 years of age). While there is a debate over if it is an overused diagnosis, the question becomes: are there inequalities behind the diagnosis of ADHD? There are some clear disparities in the diagnosis of people of color and women as well as socioeconomics playing a factor in a positive diagnosis. Interestingly, it is unclear if the diagnostic inequality with African Americans is due to racism or lack of data collection. In either case, having a disparity in a medical diagnosis of any proportion is an issue because it means there is a multitude of people who are struggling unnecessarily and could benefit from receiving a medical intervention.
Curiously, of the current demographics being studied, much of the diagnosis of the pediatric population surrounding attention deficit hyperactivity disorders are given to white males that originate from a family in a lower socioeconomic class. A study done at University of Kentucky, run by Myles Moody which was published in The Journal of African American Studies, discusses contributing factors to the school-to-prison pipeline. He includes underdiagnosing of black kids with ADHD as part of the pipeline. “…the underdiagnosis of attention deficit hyperactivity disorder in Black children is a result of racism…” Moody goes on to paraphrase a paper written in 2013 about a study done in 1999, entitled Early Childhood Longitudinal Study: Kindergarten Class of 1998–1999, to say that white children were predominantly diagnosed during middle school in comparison to the their black counterparts. “…of 17,100 children what they found was approximately 7% of white children had been diagnosed with ADHD…between kindergarten and with grade…only 3% of Black children had been diagnosed by middle school”. The long-term effect of not diagnosing a person of color seems to be minimal when in fact the results have potential for a very negative impact on a child’s life — particularly in the African American community.
Theoretically based off Moody’s study, if a child of color who is symptomatic for ADHD but is not given the diagnosis, he will become less focused in the classroom and start having trouble in his personal life because he is not studying. Moody claims that the failure to diagnose ADHD in children of color potentially can lead several problems in the future. As an example, kids being punished for not focusing on the classroom, or being treated like a criminal for struggling with academic performance or constantly being late for class. The school to prison pipeline can be reduced by properly diagnosing people from all demographics. It is disturbing that one group in the population appears to be so underdiagnosed for ADHD (Shi Y, Hunter Guevara LR, Dykhoff HJ, et al.) but based on historical context and based on another common misdiagnosis it is not surprising.
Based on historical context for dishonest research practices in the African American communities, such as the Tuskegee syphilis disaster, it makes sense to contribute the underdiagnosis to racism. Even though it might be a stretch to say this because there is a lack of empirical data, it seems that maybe the lack of diagnosis has to do with the parent’s knowledge of what ADHD is. In a study done by Regins Bussling and et. al. published in The Journal of Family issues in 2007, they found that “…Most parents had heard about ADHD and considered themselves knowledgeable…compared to their Caucasian counterparts, African American parents reported less ADHD awareness and lower self-rated knowledge…” While Moody is content to say that the diagnosing physician has a racial bias which leads to a systemic issue of African Americans not being diagnosed. Regin’s study points to a more widespread issue: the lack of information communicated to the African American community. An implicit racial bias is hard to correct on a large scale but having a community that lacks information can be fixed. The argument that a lack of information is the cause of disparities in diagnosis in African Americans is sensical because African American parents do not fully understand what ADHD is and have a negative perception of t according to a study done by Olaniyan et al. “Some perceived that children were labeled with ADHD because of poor educational environments that were unresponsive to the needs of AA children.”
This is backed up Busslings study “…Furthermore, they made more etiological attributions to sugar intake and expected less benefit from treatment…” These decisions and assumptions that the non-Caucasian parents made, were not made because they were stupid. These people had different backgrounds and styles of education and the schools do not provide resources to educate a particular demographic of people. The African American parents in the study and the portion of the population whom they represent made the assumptions that their kids were not content rations and acting hyper based on the communal knowledge which they knew from how they were raised.
Without a doubt there is some racism in the medical community with regards to who gets a diagnosis. And there is a relationship between racism and black kids not being properly diagnosed with ADHD per Moody’s study. But the racism for the most part is not overt. The racism stems from a certain way in how the medical schools teach and train doctors to diagnose white kids. This creates a learned, implicit bias.
Looking at ADHD, there is no qualitative or quantitative data to back up any kind of proof for overt racism being a root cause in ADHD diagnosis disparities. While on the other hand there is data to back up the lack of information provided to African American parents such as with a study testing cues regarding ADHD. This suggests that the conversation surrounding the lack of ADHD diagnosis in the African American community should be about why there is a lack of resources (in the form that they would be most receptable to learning from) being provided to non-white parents about ADHD and how they can get resources to help their children.
The issue that keeps popping up in writing this paper is the lack of data. When researching disparities in ADHD, there is data and research being done in almost every category. The data that is not being tracked by sociologists and medical professionals is if all children who get recommended for testing and treatment by schools get the help they need, if not, is it because of cost or lack of understanding or something completely different and what is the person’s demographics?
African Americans are not the only demographic in which there are diagnostic differences with ADHD. It is known that there is an inequality in the level of medical care for women. For a young female child this is no different when it comes to being diagnosed with ADHD. This is because for many years it was assumed that ADHD was a male disease. Later it was discovered that women have ADHD as well. However, both women and men present with ADHD differently. In fact, according to Holthe, M. E. G., & Langvik, E. in their study (2017) they found based on other studies as well that boys were more likely to be diagnosed with ADHD than girls. The ratio was for every three boys diagnosed; one girl would get diagnosed.
There is plenty of research on the male and female presentations of ADHD. However, except for two to three studies not a whole lot has been done to rectify the problem of women’s mental health, specifically with regards to ADHD not being looked at when there are more males diagnosed. It is possible that this lack of data is part of a more systematic issue. But also, the same issue that causes issues with misdiagnosis with African Americans is true for women as well; the medical students learn to diagnose white males. This means that women are less likely to get a correct diagnosis in general. But specific to ADHD, Female African Americans or the least likely to be helped or diagnosed based on the statistics presented earlier.
The disparities in diagnosing ADHD are small issues that all come together to create a big whopping mess. These issues overlap with other systemic problems. But regarding ADHD diagnosing in the pediatric population, it boils down to two main issues: race and gender. But these are part of an overarching category of lack of communication with parents. To oversimplify, this can be fixed by providing resources to explain what ADHD is, and why the child in question needs testing, in a format that is consistent with the parents’ background. The other issue that appears is socioeconomic status. But there is no explanation or proven link to what connects the socioeconomics of a family to have an ADHD diagnosis. By providing more resources, it can cause more children to receive help and create more success in minority populations.
Resources:
Moody, M. (2016). From Under-Diagnoses to Over-Representation: Black Children, ADHD, and the School-To-Prison Pipeline. Journal of African American Studies, 20(2), 152–163. http://dx.doi.org/10.1007/s12111-016-9325-5
Holthe, M. E. G., & Langvik, E. (2017). The Strives, Struggles, and Successes of Women Diagnosed With ADHD as Adults. SAGE Open. https://doi.org/10.1177/2158244017701799
Shi Y, Hunter Guevara LR, Dykhoff HJ, et al. Racial Disparities in Diagnosis of Attention-Deficit/Hyperactivity Disorder in a US National Birth Cohort. JAMA Netw Open. 2021;4(3):e210321. doi:10.1001/jamanetworkopen.2021.0321
Machlin, L, McLaughlin, KA, Sheridan, MA. Brain structure mediates the association between socioeconomic status and attention-deficit/hyperactivity disorder status. Dev Sci. 2020; 23:e12844. https://doi.org/10.1111/desc.12844
Olaniyan, Omolara & Dosreis, Susan & Garriett, Victoria & Mychailyszyn, Matthew & Anixt, Julia & Rowe, Peter & Cheng, Tina. (2007). Community Perspectives of Childhood Behavioral Problems and ADHD Among African American Parents. Ambulatory pediatrics: the official journal of the Ambulatory Pediatric Association. 7. 226–31. 10.1016/j.ambp.2007.02.002.
