Evaluating and Treating ADHD in African American Children: Guidance for Clinicians
“To ensure more equitable health care, clinicians must recognize these issues in broader society without assuming that a universal African American experience exists; great care requires clinicians to probe and consider each individual patient’s unique experiences.”
Racism, structural bias, and individual discrimination are linked — in research new and decades old — to adverse health outcomes for racial and ethnic minorities. This is a fact of American medicine. And it plays out every day in the assessment and treatment of attention deficit hyperactivity disorder (ADHD or ADD) in African American children, who are both under-diagnosed with and inadequately treated for the condition.
To ensure more equitable health care, clinicians must recognize these issues in broader society without assuming that a universal African American experience exists; great care requires clinicians to probe and consider each individual patient’s unique experiences, and the role that ADHD stigma plays in BIPOC communities.
In other words, a clinician’s “cultural considerations” and “cultural competence” cannot guarantee proper diagnosis and care for all patients. That process requires the clinician to embrace cultural humility.
Cultural Competence vs Cultural Humility
Culture is More Than Race
A patient’s race does not entirely define their cultural picture, and cultural considerations in health care should not hinge on race alone. This is a meaningful starting point for clinicians; it sets the tone for patient care at all phases.
Consider three young African American boys: One boy is from Chicago’s inner city and has been exposed to community violence and other structural issues. Another boy is from one of the affluent suburbs of Maryland’s Prince George’s County. The third grew up in the Mississippi Delta. These boys are all young and African American, but it is impossible to generalize their experiences. Their cultures, including the other cultures to which they’ve been exposed, the factors that shape their internal and familial resources, and how they may think about mental health engagement or treatment — are all going to be significantly different.
Yet, the prominent portrayal of African American children tends to match that of the first child, who grew up in a hyper-segregated, inner-city community. This is certainly not where all Black children live, and even Black children in these communities don’t have universal experiences.
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Cultural Humility Over Cultural Competence
Cultural competence training for clinicians, while well-intentioned, often narrowly centers on race, leaving out the other factors that make up an individual. This approach suggests that clinicians need only demographic data and information on the patient’s race in order to ensure appropriate clinical care and engagement. Such an idea implies an endpoint to their work.
Clinicians should instead strive for cultural humility – the idea that the patient’s family is the expert on the child and their situation. The patient’s expertise is needed, and cultivating this relationship is a two-way process. The clinician educates the patient and family about ADHD, and the caregiver informs the clinician about the child’s realities, challenges, and ideas about ADHD and other neurological and mental health issues.
Examining Societal Forces and Adjusting Understanding
Is the barrier cultural or structural? Is it a disparity or an inequity? Clinicians should consider and question the societal drivers that affect a group of people. Doing so can help clinicians intervene and become part of the solution. It is often said, for example, that African Americans have a cultural distrust of providers. But understanding the legacy of mistreatment and abuse that African Americans have faced and continue to face by the medical system forces us to see the issue differently. It’s not that these communities are unwilling to trust – it’s that health care systems haven’t shown themselves to be trustworthy.
Similarly, “disparities” is a term used to describe differences in access to and quality of medical care among Black and white populations. But these differences are better described as “inequities,” a term that invokes the structural forces and injustices at play.
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Trauma and Its Implications
Considering trauma is critical when assessing for any mental health condition. When it comes to African American children, the implications of trauma take on a greater weight.
Trauma and African American Children
Black children as a whole are more likely to be exposed to trauma than are white children. Trauma can mean interpersonal trauma, which includes abuse and neglect, but it can also take on forms that aren’t as widely appreciated.
- Racial trauma: Experiences like seeing images of people children relate to being harmed or killed on social media is a form of racial trauma. Experiencing racism in the school setting or in the neighborhood are other examples.
- Structural trauma occurs when the systems that are entrusted with children’s livelihoods are actually harmful to them. This can look like a Black student experiencing unfair disciplinary treatment in school compared to white students.
Assessing ADHD Symptoms in Context
Context is extremely important when evaluating for ADHD in children, especially Black children. Symptoms of ADHD can overlap with other mental health conditions. ADHD is often the default diagnosis when a clinician observes symptoms that resemble inattention, hyperactivity, and impulsivity, which may be caused by other drivers, including:
Racism: A child’s motivation in school essentially relies on a belief that they have a stake in their future. This can be difficult for African American children to believe when they see people who look like them being harmed for just being, or when they are in a neighborhood with constant community violence, or when they see people who have been neglected and stuck for generations. School engagement also suffers when children feel targeted, rather than encouraged, in the environment.
Depression: The most common mental health illness following trauma, which disproportionately impacts Black children, is depression. One of the core symptoms of depression is lack of concentration, which can lead to inattention, a symptom of ADHD. Children can also experience agitated depression, which can resemble hyperactivity. Screening for depression is therefore key.
Anxiety and worried thoughts: A child will likely have anxiety and worried thoughts if facing issues like food insecurity, domestic violence, and other traumas and social stressors. Nightmares and flashbacks may indicate that the child is not getting adequate rest. Some children may also experience restlessness from anxiety, or reactivity from trauma. All of these factors impact concentration and can look like inattentiveness and hyperactivity.
Learning disorders: Difficulty paying attention may stem from unaddressed learning disabilities. Understanding the significance and brunt of structural issues, including delays in proper testing or diagnosis, is critical.
Survivor behaviors: Closely related to trauma is recklessness and survival behaviors, which can resemble impulsive behaviors. If children live in a community where a quick reaction is necessary to protect themselves, it can be hard to turn that off when in school.
Observer bias: Black children are more likely to be seen as problematic already in the classroom by the school system, a problem exacerbated by society’s lack of acknowledgement of Black pain and how it manifests in children.
Unrealistic developmental expectations: A child’s behaviors can be mislabeled as symptoms of hyperactivity and impulsivity tied to ADHD when there could be other factors at play, like getting accustomed to having a new, younger sibling.
Low salience: If the child can’t relate to the lessons taught in school, it will be hard for them to become invested in them, which can be mistaken for inattention as related to ADHD.
Approaching Treatment and Intervention
Barriers to Care
Despite beliefs in some Black communities that ADHD is over-diagnosed and over-medicated in Black children, data shows that ADHD is actually under-diagnosed in Black children compared to white children. Black children with ADHD are also less likely to get treatment compared to their white counterparts. Contributing factors include:
- Low tolerance for perceived behaviors: Multiple studies show that society views Black children as older and less innocent compared to white children – a discriminatory pattern that explains why Black children are also more likely to be criminalized for problem behaviors.
- Educational failure: The school-to-prison pipeline and the heavy policing of under resourced schools and communities significantly impacts life trajectories for Black children.
The Role of the Provider
For treatment to succeed, clinicians must make it a point to show themselves as trustworthy to patients, and to acknowledge the role that the medical system plays in the realities that patients face. A collaborative approach is key.
Devising a Treatment Plan That Centers on Family Choice
The best treatment plan for any child or family is the plan that they are able and willing to follow. Clinicians should learn about how patients and families feel about the child’s diagnosis and the possibility of medication, and what resources the family can access.
ADHD Medication Considerations
Families may be reluctant to consider medication for ADHD given:
- potential prior negative experiences with the medical system
- fears about dependency and substance abuse (which is disproportionately criminalized in Black communities)
- stigma surrounding medication and mental illness
Clinicians should engage in conversations with families about what the child’s diagnosis and the possibility of medication mean to them. Some families, for example, may bring up the difficulties surrounding being a Black person in a racist society, and having that compounded by mental illness and medication — both of which are still commonly stigmatized.
As part of the conversation, and to allow patients and families to make informed choices, clinicians must explain what medications do and don’t do. They should make sure families understand that medication used as instructed will not lead to issues like negative obesessive use. Not every family will have the same fears, so clinicians should ask questions and listen intently to concerns.
Families should also be aware that medication should be part of a larger treatment plan; it is not a cure-all. For example, an untreated child with ADHD who is significantly behind in school will not catch up after taking ADHD medication. They may need medication, along with tutoring and other academic services. They may also need an evaluation to rule out other learning issues, and/or psychotherapy to address any trauma they’ve experienced.
Understanding issues around insurance and family dynamics is imperative. Black children are more likely to be publicly insured, meaning that the medication formulations available to them are limited. Black children are also more likely to be in single-parent households – dosing schedules may depend on the parent’s busy schedule and school nursing services.
Next Steps for Clinicians
- Self Study: Clinicians should avoid aiming for competency alone. Being aware of and continuously learning about historical and current factors (at the local level and beyond) can help clinicians contextualize experiences and issues as they relate to Black communities.
White clinicians must contend with their ingrained biases and examine any defensiveness and fragility that comes with it in order to really address larger, structural issues.
- School Awareness: As childhood ADHD is mostly commonly diagnosed while the patient is in school, clinicians should have a strong grasp on how local school districts work. This includes knowing what resources they have and what inequities exist in terms of access to school counselors, therapists, and psychoeducational testing. Basic knowledge of the school system should inform treatment planning.
- Continuously Center Families: Clinicians should be guided by an understanding that any intervention that supports the primary caregiver and the family unit, including helping them feel heard and informed, is important. Failing to consider broader issues could exacerbate symptoms, and may cause or contribute to any distress the child is experiencing.
Cultural Considerations in ADHD: Next Steps
- Read: ADHD Clinicians Must Consider Racial Bias in Evaluation and Treatment of Black Children
- Download: 7 Biggest ADHD Misdiagnosis Mistakes Doctors Make
- Understand: How Race Impacts Ratings of ADHD Behavior in Black Boys
The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude
- How can I better understand ADHD, its causes, and its manifestations?
- What do I need to understand about ADHD that is not fully represented in the DSM?
- How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
- How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
- How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
- How can I best consider trauma and personality disorders through the lens of ADHD?
- What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?
The content for this article came from the webinar titled “Cultural Considerations When Diagnosing and Treating ADHD in African-American Children” with Sarah Vinson, M.D. Access the webinar replay and accompanying resources here.