ADHD and Race in the School Setting
Catherine L. Montgomery & Kevin Antshel, Ph.D.
Department of Psychology
ADHD Lifespan Treatment, Education, and Research (ALTER) Program
The prevalence rate of ADHD in the United States varies by race/ethnicity; notably, rates of ADHD diagnoses in Black children are estimated to be 65% to 75% of rates of diagnosis in White children of similar SES and symptom severity. (See (Miller, Nigg, & Miller, 2009) for a review of this literature.) ADHD diagnostic practices rely on collecting multiple informant (i.e., parent, teacher, and child) ratings of symptoms. These ratings may be impacted by the actual ADHD symptoms, the context (school v. home) or characteristics about the informant (Kraemer et al., 2003). Over 80% of primary and secondary school teachers are White (U.S. Department of Education, 2017). Thus, one potential contributor to the identified ADHD racial discrepancy rates may be differences in how Black parents and White teachers consider a child’s behaviors.
To investigate this hypothesis, Kang and Harvey (Kang & Harvey, 2019) recently compared ADHD ratings of 71 Black parents (92% female) to those of 60 White teachers (68% female) and 65 White parents (75% female) recruited through Amazon’s Mechanical Turk (MTurk). Participants watched ten 1-minute video clips of children in actual preschool, Kindergarten, 2nd grade and 3rd grade classrooms which were posted publicly on YouTube. Within each classroom, one child served as the target child for participants to rate. Two Black boys, two Black girls, two White boys, two White girls, one Asian boy and one Latina girl served as targets with the order of the children counterbalanced between participants. All participants watched the same 10, 1-minute video clips. Following each video, participants completed Vanderbilt ADHD symptom checklists and rated the likelihood of the target child having ADHD (1 = Very Unlikely – 6 = Very Likely). Only 11 items were used from the Vanderbilt. These 11 items were chosen based off of what could be readily observed from a video. Importantly, the parent and teacher ratings were compared against each other and not an external “gold standard”. Thus, conclusions about the accuracy of a reporter’s ratings could not be reached. Finally, the authors’ also examined beliefs about ADHD stigma, verve (movement expressiveness), experiences with racial discrimination, and racial attitudes as potential explanations for racial differences.
- White teachers rated Black boys’ ADHD behaviors (d = .33) and ADHD likelihood (d = .44) higher than Black parents. No differences emerged between White teachers and White parents for Black boys’ ADHD behaviors and ADHD likelihood.
- No group differences emerged for Black girls, White boys or White girls.
- Black and White parents aligned well in their ratings of all children except for Black boys.
- White teachers with more negative racial attitudes gave significantly higher ADHD behavior (r = -.30) and likelihood (r = -.45) ratings to Black boys than those with less negative racial attitudes. Teacher’s racial attitudes were not related to any other child’s ADHD ratings or likelihood.
- There was a positive relationship between Black parents’ experiences with racial discrimination and ratings of all children’s ADHD behaviors.
- No group differences emerged for ADHD stigma beliefs.
- Neither ADHD stigma beliefs nor verve were related to any group’s ratings.
Kang and Harvey reported significant racial differences in ratings of Black boys’ ADHD behaviors and likelihood, a finding which other studies have similarly reported (Harvey, Fischer, Weieneth, Hurwitz, & Sayer, 2013; Lawson, Nissley-Tsiopinis, Nahmias, McConaughy, & Eiraldi, 2017). Kang and Harvey held the context constant (all actual classrooms) and suggest that these differences are due, at least in part, to racial differences in adult perception as opposed to contextual differences present in different settings (e.g., home versus school). Kang and Harvey concluded that it remains unclear if these discrepancies are due to Black parents underestimating Black boys’ symptoms or White teachers overestimating Black boys’ symptoms.
These findings may help to explain the lower rates of ADHD diagnosis in Black children. The DSM-5 criteria emphasize the importance cross-situational symptoms when diagnosing ADHD. If parents and teachers are not reporting the same symptoms at the same severity, then a diagnosis is less likely. Kang and Harvey offered several clinical and practical implications such as the implementation of teacher interventions to reduce the role of racial biases, the provision of more explicit instructions for completing ADHD rating scales, and bringing awareness of these racial discrepancies to clinicians. Additional research on this topic is necessary to further explain the variation in the rates of diagnosis. For example, Black teachers were not recruited for the current study, and including Black teachers may reveal more about the discrepancy. Future research could also consider additional mechanisms that might explain the observed racial differences in adults’ perceptions of ADHD behaviors in Black boys. Finally, a design which includes more than 1-minute of child behavior may enhance the ecological validity of the ratings.
For further reading on this topic, please consider DuPaul’s excellent commentary on this study (DuPaul, 2020).
DuPaul, G. J. (2020). Adult Ratings of Child ADHD Symptoms: Importance of Race, Role, and Context. J Abnorm Child Psychol. doi:10.1007/s10802-019-00615-5
Harvey, E. A., Fischer, C., Weieneth, J. L., Hurwitz, S. D., & Sayer, A. G. (2013). Predictors of discrepancies between informants' ratings of preschool-aged children's behavior: An examination of ethnicity, child characteristics, and family functioning. Early Child Res Q, 28(4), 668-682. doi:10.1016/j.ecresq.2013.05.002
Kang, S., & Harvey, E. A. (2019). Racial Differences Between Black Parents' and White Teachers' Perceptions of Attention-Deficit/Hyperactivity Disorder Behavior. J Abnorm Child Psychol. doi:10.1007/s10802-019-00600-y
Kraemer, H. C., Measelle, J. R., Ablow, J. C., Essex, M. J., Boyce, W. T., & Kupfer, D. J. (2003). A new approach to integrating data from multiple informants in psychiatric assessment and research: mixing and matching contexts and perspectives. Am J Psychiatry, 160(9), 1566-1577. doi:10.1176/appi.ajp.160.9.1566
Lawson, G. M., Nissley-Tsiopinis, J., Nahmias, A., McConaughy, S., & Eiraldi, R. (2017). Do parent and teacher report of ADHD symptoms in children differ by SES and racial status? Journal of Psychopathology and Behavior Assessment, 39, 426-440.
Miller, T. W., Nigg, J. T., & Miller, R. L. (2009). Attention deficit hyperactivity disorder in African American children: what can be concluded from the past ten years? Clin Psychol Rev, 29(1), 77-86. doi:10.1016/j.cpr.2008.10.001
U.S. Department of Education, National Center for Education Statistics, Schools and Staffing Survey (SASS), “Public School Teacher Data File,” 2003–04; and National Teacher and Principal Survey (NTPS), “Public School Teacher Data File,” 2015–16. (2017). Public School Teacher Data File, 2003–04 and National Teacher and Principal Survey (NTPS), Public School Teacher Data File, 2015–16. Washington, DC.