He Just Needs to Behave

Racial bias in the diagnosis and treatment of ADHD.

Posted Nov 23, 2020

By Elsa Friis, PhD on behalf of the Atlanta Behavioral Health Advocates

Photo by August de Richelieu from Pexels
Source: Photo by August de Richelieu from Pexels

“Just sit down and do your homework!” My frustration was getting the better of me as I re-directed an 11-year-old to do his homework while I tried to cook dinner and make sure 5 other children were similarly finishing their homework (or at least not fighting or setting things on fire). My time working as a live-in caregiver and academic support provider at a group home in Baltimore tested my patience at times and opened my eyes to systemic inequities and bias in mental healthcare and education for Black and Latinx children.

I started working at the group home right after college, and it didn’t take long for me to have concerns that a few of the children in our care had attentional and learning challenges. In fact, in two cases, the attentional concerns were so significant, I was flabbergasted that there was no existing diagnosis of ADHD or any history of psychological or academic testing.

Unfortunately, this experience is not uncommon, as Black and Latinx children are more likely than their White counterparts to have a delayed diagnosis in ADHD or are never diagnosed (Morgan et al., 2014). My personal experience of trying to advocate for psychoeducational assessment for these children was frustrating, confusing, time-consuming, and complex. Once there was a formal diagnosis of ADHD, I was surprised by how, seemingly, there was little modification in teacher and counselor perceptions or approaches. Admittedly, as a White woman, I was initially unaware of the bias and discrimination experienced by the Black and Latinx children in our care. But slowly – through education and consultation with Black colleagues and parents — I started to decode some of the feedback I received from their teachers. 

Here are a few examples: 

Teacher’s Feedback: “What can you really expect with his family situation and academic history?”

Underlying Message: “We don’t think he can succeed.”

Teacher’s Feedback: “He just needs to learn how to listen and behave.”

Underlying Message: “This is a bad kid, not a kid who just has challenges sitting still and paying attention.” 

Teacher’s Feedback: “He is behind, but I guess not as bad as I would expect with his background.”  

Underlying Message: "We don't think Black children from inner-city Baltimore can achieve at high levels."

These are just a few examples of how children of Black and Latinx children with ADHD are more likely to be labeled as "disruptive," "not academically inclined," or "misbehaving" than their White peers. This sets them on the trajectory to receive more discipline in the classroom, rather than the extra support and guidance they need to succeed.

These messages are often internalized by children, a fact we may often forget or fail to consider. Indeed, after a rocky Individualized Education Plan meeting, the student I was working with defeatedly expressed, “If all they expect of me is to drop out because I am Black, what is even the point of trying?” This was a heartbreaking statement to hear from a child who I knew was smart, absurdly creative (he was writing his own comic book), sensitive, caring, and full of dreams and aspirations.  

Sadly, this is not a ‘one-off’ story. Many Black and Latinx families have similar stories. What may be different is we were lucky enough to connect this child with a wonderful (and culturally competent) therapist and several mentors who provided immeasurable help, tips, and support. The perceivably effective care he received is sadly not the norm for many other Black or Latinx children, who are more likely to receive a lower quality of care and are more likely to drop out of care after just a few meetings as compared to their White peers (Coker et al., 2016) While we do not know exactly why this may be, there are some proposed driving factors:

  1. Limited access to high quality and culturally responsive care
  2. Healthcare provider bias 
  3. A lack of culturally sensitive diagnostic measures
  4. Bias in teachers and other caregivers, with Black Indigenous and People of Color (BIPOC) children being more likely to be labeled as having behavioral rather than attentional concerns
  5. Cultural differences in perceptions of mental health and mental health stigma may contribute to families not sharing concerns.

What you can do

If you are a parent, teacher, or therapist wondering what you can do to counteract racial discrimination and inequities in care, here are some suggestions: 

  1. Be aware. Recognize the disparities and how they might influence your behavior.
  2. Recognize that there is implicit bias, and try to check your own bias. 
  3. Advocate! For your children, for the children you teach, and for your clients!

Want to learn more?

How to advocate for your child with ADHD

Education and resources provided by the Duke ADHD Program (Facebook page)

Race and ADHD blog by Dr. Joel Nigg

References

Morgan, P. L., Hillemeier, M. M., Farkas, G., & Maczuga, S. (2014). Racial/ethnic disparities in ADHD diagnosis by kindergarten entry. Journal of Child Psychology and Psychiatry, 55(8), 905-913.

Coker TR, Elliott MN, Toomey SL, et al. Racial and Ethnic Disparities in ADHD Diagnosis and Treatment. Pediatrics. 2016;138(3):e20160407. doi:10.1542/peds.2016-0407