These inequities are especially important to recognize, experts say, because common symptoms of ADHD, like impulsivity, hyperactivity, disorganization, and inattention, can pose significant challenges if they’re not treated, particularly in marginalized populations. “The consequences of untreated ADHD for Black children are substantial and can lead to harsh punishment in school, school failure, substance use, justice system involvement, and the many life consequences that can follow,” says Tumaini Rucker Coker, MD, a professor and division chief of general pediatrics at the University of Washington in Seattle, who conducts research related to health equity and disparities in primary care. Here’s what researchers know so far about why ADHD is underdiagnosed, misunderstood, and undertreated in communities of color — and potential solutions to the problem.
Race and ADHD: What Research Tells Us
Most studies of the relationship between race and ADHD show that children of color are underdiagnosed and undertreated for the disorder compared with white children, Dr. Coker says. Coker and a team of researchers assessed nearly 4,300 children in grades 5, 7, and 10, for instance, and found that although African American children in the study exhibited more symptoms of ADHD than white children, they were diagnosed less frequently and were less likely to take an ADHD medication. Latino children were just as likely to show ADHD symptoms as white children but less likely to be diagnosed or treated. Among 10th grade children with the highest level of ADHD symptoms, only 36 percent of African American children and 30 percent of Latino children with ADHD took medication, compared with 65 percent of white children. The study was published in September 2016 in the journal Pediatrics. Another study, published in March 2021 in JAMA Network Open, produced similar results, showing white children with ADHD were more likely to be diagnosed with and treated for it compared with Black, Hispanic, and Asian children with ADHD. Researchers examined data on more than 17,000 children in the United States in another study, published in Pediatrics. They found that compared with white children, Black children were 36 percent less likely and Latino children were 56 percent less likely to be diagnosed with ADHD. This disparity extends to ADHD treatment, too, and researchers have found that racial inequalities related to treatment have persisted over time, according to a review of 41 studies, published in September 2021 in the Journal of Racial and Ethnic Health Disparities.
The Consequences of Racial Disparities in ADHD Are Serious — Even Life-Threatening
The consequences of unrecognized and untreated ADHD among children within marginalized racial and ethnic communities can be serious and severe, according to Loucresie Rupert, MD, a child, adolescent, and adult psychiatrist at Gundersen Health Systems–Insightful Consultant, in La Crosse, Wisconsin, who specializes in behavioral and developmental disorders. “ADHD can be really dangerous if it’s untreated, like endangering your life,” says Dr. Rupert, who found out during her medical residency that she, herself, has ADHD. “Sometimes, I have 4-year-olds who are so impulsive that they do dangerous things, like running into the street or jumping off buildings [like houses].” In fact, individuals with ADHD have more than double the risk of death, most often due to unnatural causes such as accidents, compared with those without the disorder, according to a study published in February 2015 in The Lancet. The authors of the study add that having a co-occurring condition, like oppositional defiant disorder, conduct disorder, or a substance use disorder, exacerbates this risk. What’s more, children with ADHD also have a two- to threefold increased risk of being arrested, convicted, or incarcerated in adulthood, according to a study published in August 2016 in Clinical Psychology Review. This is what’s known as the “school-to-prison pipeline,” says Rupert. “If you get in trouble at school, and you don’t have a ‘reason’ for your behavior, they just call the police [rather than help the child get the help they need],” Rupert adds. It’s another reason this disparity in ADHD diagnosis and treatment is especially dangerous for marginalized racial and ethnic communities. Poor academic performance in school is yet another outcome of untreated ADHD. Research shows children with ADHD were more likely to be absent from school more often, to be held back a grade, and to drop out before high school graduation than those without ADHD.
Why Do These Racial Inequities Exist?
The reasons for racial disparities in ADHD-related care are not fully understood, suggests the aforementioned study published in March 2021 in JAMA Network Open. Most experts believe the problem may be due to complex societal and cultural factors. “In general, these disparities cannot be explained by differences in mental health need or family socioeconomics, so the reasons for the disparities largely lie within our own systems for diagnosis and treatment,” Coker explains.
Systemic Racism and Stereotyping Play Key Roles
Systemic racism — or widespread discrimination that’s embedded in the laws and systems of society — seems to play a strong role in contributing to disparities in ADHD care, according to Coker. “It is important to recognize that race is a social construct, so the relationship between race and ADHD in the United States that has been documented across multiple studies is due, at the core, to racism,” explains Coker. Racial differences in screening tools and provider biases, Coker explains, are two examples of flaws in our health system. According to the aforementioned study published in March 2021 in JAMA Network Open, clinicians may interpret identical behaviors displayed by Black and white children differently, based on racial stereotypes and expectations. This could result in these behaviors being identified as “disordered” among white kids but inappropriately labeled as “normal” among Black kids, according to the study authors. Rupert says that even preconceived beliefs held by teachers and school staff members can contribute to the problem. “If a Black kid has behavioral problems, some people just think, ‘Oh, they’re Black, so they’re just having problems at home, and they probably come from a broken home,’ which is obviously a stereotype,” she explains.
Mistrust of the Healthcare System Is Common
Historical oppression and mistreatment may make people of color more reluctant to seek medical care for mental health conditions like ADHD, according to Mental Health America. One well-known example is the U.S. Public Health Service (USPHS) Syphilis Study at Tuskegee, in which 399 African American men with syphilis were purposely not given treatment. “There’s a legitimate fear of taking your kid to a physician, in general, because there has been a lot of medical abuse of Black people in America. So, there’s that real fear of your kid not being treated right,” Rupert says. Recent studies have shown that, even today, Black and Hispanic Americans are wary of the American health system. In a poll by the Kaiser Family Foundation published in October 2020, 7 out of 10 Black people said they’re treated unfairly by the healthcare system, and 55 percent say they distrusted it. And nearly 1 in 5 Hispanic people report avoiding medical care due to a concern of being treated poorly or discriminated against, according to the Centers for Disease Control and Prevention (CDC).
Mental Health Stigma Impedes People From Getting Help
Stigmas surrounding mental health may inhibit families of color from going to therapy. “In the Black community, you prayed about it. You didn’t go to therapy,” Rupert says. Although younger Black people are more open about their mental health than previous generations, Rupert explains, a systematic review published in March 2021 in Frontiers in Public Health showed that parental stigma remains a significant barrier to teens of color seeking mental health care. This research suggests that fear of having the child labeled as having a mental health disorder is a common concern for parents of children within marginalized racial and ethnic communities. People in Latino and Hispanic communities may associate openly discussing mental health problems with embarrassment or shame for their families, which could impede people from getting the treatment they need, according to Mental Health America.
There Aren’t Enough Mental Health Providers of Color
Another potential contributor to these disparities is that there just aren’t many mental health providers of color, says Rupert. “Communities like to have clinicians that look like them,” she explains. In 2015, only 4 percent of the psychology workforce were Black or African American, 5 percent were Hispanic, and 5 percent were Asian, while the remaining 86 percent were white, according to a report published in February 2019 by the American Psychological Association. What’s more, the American Academy of Child and Adolescent Psychiatry reports a severe shortage of psychiatrists for children across the board, with a median of only 11 child and adolescent psychiatrists for every 100,000 children in the United States. A shortage of bilingual mental health professionals may also be an obstacle for Hispanic people getting the help they need, per the American Psychiatric Association.
Marginalized Communities Have a Harder Time Accessing Care
Among the factors identified as obstacles to equitable diagnosis and treatment of ADHD for children of color are lack of access to high-quality care and lack of health insurance, according to a literature review published in March 2020 in Transcultural Psychiatry. African American people and people of Hispanic origin have among the lowest rates of health insurance coverage compared with white people, per one review published in April 2017 in Population Research and Policy Review.
What Solutions Could Help Bridge the Gap?
Solving racial disparities in ADHD will likely require a multisystem and multilevel response to meet the needs of Black families, according to Coker. She says this includes creating ADHD screening tools and behavioral interventions that are designed, evaluated, and implemented in partnership with families and communities. “Clinicians should ask children and parents about behavioral concerns and discuss school performance at every well child care visit,” she says. “By building more trusting relationships, which may be enhanced in team-based approaches to care, like integrating community workers into primary care teams, parents have more avenues to have their concerns addressed and heard.” Coker adds that improving access to behavioral services in schools and supporting training to increase the number of Black child behavioral providers are important steps to improving care for people in marginalized racial and ethnic communities. This access is vital because high-quality treatment for ADHD greatly boosts children’s odds of success in school, according to a study published in January 2015 in the Journal of Attention Disorders. Public efforts to destigmatize mental health care in minority children may also help lessen reluctance to seek care, says Rupert. “Part of solving the problem is going to be education,” she explains. “I think there definitely needs to be education within the Black community, but I think even more so, we need to fix ourselves first — meaning the medical and education side — because why would we expect the Black community to trust us?” She says reaching out for help is the first step to finding a solution. “From the parent side, finding your community is just huge, in knowing that you’re not going through this alone,” she says. Some ways to do this include connecting with other families with similar struggles in your community and keeping frequent communication with the teachers and staff at your child’s school. Organizations that offer help and resources for parents and children with ADHD include: Children and Adults with Attention-Deficit Hyperactivity Disorder (CHADD) CHADD offers a directory to help you locate providers and support groups in your area. You can also find information about how to start your own chapter. Attention Deficit Disorder Association (ADDA) ADDA has many resources including workshops and virtual support groups for people of color, women, parents, and the LGBTQ+ community. Child Mind Institute The Child Mind Institute is a nonprofit organization that works to transform the lives of children and families struggling with mental health conditions. The institute provides specific resources for children and teens with ADHD. American Academy for Child and Adolescent Psychiatry This organization provides helpful information for families and medical professionals via its ADHD Resource Center.
