Race and ADHD | Joel T. Nigg, Ph.D.

Discussions of ADHD, like discussions of mental and behavioral conditions generally, often are “race blind”. This is unfortunate, in that race (along with culture, ethnicity, and other important social identities) can be an important consideration in understanding the meaning of behavior that we label as ADHD. A study that appeared two weeks ago found that among American youth in the last two years, concern about societal racism is on the rise and exposure to incidents of public racism and discrimination (sadly, more visible in our society during the past couple of years), are associated with subsequent increase in symptoms of depression and ADHD, as well as higher likelihood of trying alcohol, smoking, or marijuana. While the sample included roughly equal numbers of the major American racial groups, the effects for the most part were across all kids. What do we know overall about race, racism, stereotyping, and ADHD? I briefly discussed race and ADHD in my book Getting Ahead of ADHD in Chapter 7.

Key Points To Consider:

First, it’s important to remember that race is not a biological reality. It’s a social construction. There’s no way to tell someone’s race from their genes. A person considered “Black” in the United States might be considered “White” or “Mulatto” or some other “race” in another country. On the other hand, genetically different ethnic pools do exist. During the migration of the human race around the world, different groups lived in the same areas for thousands of years. Those lineages are traceable genetically. (That’s why you can go to 23 and Me and get your potential ethnic background). However, those ethnic definitions don’t really map very well onto our socially divided groups. For example, a genome scan can identify someone as Han Chinese, but not as Asian; many other Asian peoples would not be identifiable because sufficient data are not available or there has been too much inter-mixing of formerly separate groups. Here, when I talk about race, I’m referring to the social groups in the United States: African American, Asian-American, Native American, Caucasian/European American, and the like. Although the US federal reporting rules label Hispanic as an ethnicity, not a race (one can be Hispanic-White or Hispanic-Black for instance), it’s a misnomer genetically. Hispanic Americans comprise numerous ethnic groups genetically.

These socially perceived race groups that are the primary associations of social factors like prejudice, stereotyping, and social disadvantage, because they are associated with people’s visible characteristics and behaviors rather than on their biology.

Second, we have to recognize that stereotyping is a universal reality in our culture and has real effects on behavior. Children are acutely aware of stereotypes about gender and race even before they start school. Adults are very sensitive to activation of social stereotypes in their mind that can affect their behavior, even unintentionally. One of the most striking demonstrations of this is a phenomenon known as stereotype threat. When a member of a stereotyped group is faced with a challenging situation that could activate the stereotype, their performance worsens. For example, when women and men of equal math ability and with equal math scores on standardized tests are given a new very hard math test in which gender is made salient, women do worse. If African American and Caucasian college students of equal ability and with equal scores on standardized tests are given a new and difficult test preceded by asking about their race, and told the test is a measure of intelligence, the African Americans do worse. Interestingly, if they are told the test is not related to race, the African Americans students do as well as the White students. So, racism and stereotyping can’t be ignored if we are going to accurately handle and help children with ADHD and ADHD-like symptoms.

The entire mental health sector has to consider the effects of racism, stereotyping, implicit bias, and so on. Not just ADHD. But here, I’m going to apply a couple of observations about ADHD.

What Does This Have To Do With ADHD?

In regard to ADHD, most literature related to race concerns African American and White children, so we have very limited information on other groups. here’s what we know from a limited scientific literature that does not address every race group.

Most of the body of research on ADHD is on children, mostly boys, of European-Caucasian ancestry in the United States, Europe, Australia, New Zealand, Canada, and Brazil. We thus know something about national variation but comparatively speaking, almost nothing about ADHD’s validity and meaning in under-represented groups.

Teachers and African American parents rate African American children as more active and impulsive than teachers and Caucasian parents rate Caucasian children. Therefore, the national norms for an ADHD cut-off are different, or should be, for a Black or a White child. It’s unclear why this is—it could be that most adults in the United States have internalized a stereotype about African American children; it could be that there is a cultural variation in behavior (for example, many African Americans are encouraged to call out in church and speaker-audience interactions, whereas many Caucasian Americans are encouraged to listen respectfully in those settings. Maybe “calling out in class” has a different meaning for Black and White children.

Diagnosis and treatment of ADHD is less common in African American and Hispanic-Latino children than White children, although minority youth are catching up—rates of diagnosis are increasing faster in minority than majority children. When children do access treatment for ADHD, however, African American and Hispanic/Latino youth are more likely than other groups to discontinue treatment or get treatment only intermittently. All this could be for many reasons: lack of access to care; different thresholds for believing a behavior is a problem; different perceptions of the value of mental health services versus other resources such as religious leaders or self-help groups; as well as differential behavior of treatment providers (e.g., lack of culturally appropriate treatment provision).

ADHD is associated with social disadvantage and adverse childhood experiences. So is race, and Hispanic ethnicity. It may be that there really are more “drivers” of ADHD-related behaviors in disadvantaged communities of color—more social distress, more adverse experiences, more exposure to toxic pollutants, poor quality schools, lower quality food in stores, and so on. Thus, there may be real racial differences in ADHD due to different exposure to ADHD risk factors in the environment. Remember ADHD is best thought of as blend of genetic liability and environmental exposures that cumulatively drive the behavior and inattention.

Appropriate parental strategies for child misbehavior may vary by race—maternal and paternal parenting styles appear in several studies to have different correlations with child outcome depending on race and ethnicity. This area clearly needs more investigation.

A small number of experiments used controlled methods to try to assay the effect of stereotyping on ratings of ADHD symptoms. The most notable of these studies used different groups on the Pacific rim that resembled ethnicity as much as American race—Japanese, Hawaiian, Chinese, and Caucasian children. Raters were similarly varied in ethnic/race group. Using video of child actors to ensure that all raters saw the exact same behavior, the study showed marked stereotype effects on ratings of ADHD symptoms, across all rater groups. A second study looking at African and European children in England had a similar finding. A third study found that while Native American youth had higher ADHD inattention scores than white youth, this effect was largely explained by level of acculturation to mainstream white culture. Overall, while these are small preliminary studies, they do support the idea that stereotypes and acculturation somehow influence ratings of ADHD symptoms.

Recommendations:

If you are in an under-represented minority group trying to understand if your child has ADHD, recognize that yes, he or she might. But the diagnostic process is complicated by race and stereotype effects. Your clinician should be mindful of race-specific norms, should consider potential for implicit bias (unconscious stereotype uses even by the well-meaning) which can affect everyone’s perception of the child, and should consider social dynamics (is this child isolated, traumatized, and so on). Finally, careful attention should be paid to impairment—are the ADHD symptoms really interfering with your child’s development? A further caution—the diagnosis of conduct disorder should be scrutinized very carefully before it is applied to African American children, as it is clearly over-applied here and social drivers of disruptive behavior have to be further considered.

On the science side, we can’t yet be sure that ADHD criteria identify the same children across race and ethnicity. Some evidence says yes, some says not quite. Additional studies that take into account race, acculturation, and identity remain important, and sadly neglected.