ADHD and Race in the School Setting

Apr 24, 2020 | Editorial, Recent

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
Syracuse University

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, 2^nd grade and 3^rd 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.

Results indicated:

• 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).

Citations

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.

Managing ADHD in College Students During COVID-19

Apr 10, 2020 | Editorial, Recent

Managing ADHD in College Students During COVID-19

Afton Kapuscinski, Ph.D. & Kevin Antshel, Ph.D.

Syracuse University

The dynamic and rapidly developing COVID-19 pandemic has affected us all. Rather than focusing on the totality of the impact, we are electing to focus on what we know best: college students with ADHD. Below, we outline ideas to help college students with ADHD cope and function well despite the substantial disruptions caused by COVID-19. Managing ADHD during a global pandemic is, to our knowledge, not a topic that has been previously investigated. Thus, when developing these considerations, we relied upon our knowledge of the science of clinical psychology as well as our combined near 30-years of clinical experience working with college students with ADHD.

College students, especially those who were living away from home, are likely to be experiencing significant disruption to their daily lives. Not only has their primary residence suddenly changed, but they have also lost social supports, as well as the structure provided by academic and extracurricular obligations. Before COVID-19, many studies reported that college students with ADHD were already at increased risk for depression and anxiety. The jarring changes to daily life and uncertainty about when normal life will resume may well increase prevalence rates of depression and anxiety in students with ADHD. While some feelings of fear and loss are normative  (COVID-19 is a legitimate threat), those with pre-existing anxiety and depression may have a more difficult time managing the intensification of these emotions.

When channeled appropriately (e.g., not at panic levels), fear and anxiety can be quite adaptive and help us follow CDC guidelines cautiously to “flatten the curve”. However, very high levels of anxiety often lead to difficulty with concentration and completing tasks. Additionally, a larger, more long-term concern is the potential for depression to set in as weeks of social distancing and restriction of activities likely turns into months. In an effort to help with both proximal anxiety as well as the greater distal threat (depression) in an already vulnerable population, several of the following may be beneficial to consider for college students with ADHD:

1. Be mindful of media consumption levels. Media headlines, news alerts and social media are likely to be rife with the most tragic and dramatic stories (e.g., celebrities who have died from COVID-19). Consuming excess media (probably defined by the extent to which catastrophizing occurs) likely leads to a loss of balanced perspective (Jenness et al., 2016) and the adoption of irrational beliefs (e.g., I won’t be able to graduate college). Consider silencing news alerts or using screen time limits to moderate media exposure.
2. Establish routines. Everyone’s daily routines have been impacted. Rather than getting lost in a cycle of Netflix and gaming, it is important to re-establish routines. If uncertainty is the poison, routines are the antidote. In our experience, the importance of sleep-wake cycles as the first routine to re-establish cannot be overstressed (Lyall et al., 2018). Routines related to medication adherence, physical activity and coursework should be the next ones added to the daily schedules.
3. Establish physical boundaries. Being at home 24/7 increases the risk for a blurring of boundaries between work and recreation. Develop specific places to do school work that are separate from recreation spots. If this is not possible, develop some rules (e.g., I won’t browse YouTube until after 3 PM).
4. Maintain social supports. Stay connected in real time with sources of social support from college through phone calls, Facetime, and Zoom (e.g., virtual throwback dance parties!). It is unfortunate that the public health officials labeled it “social distancing”. In our opinion, “physical distancing” is a better term and belies the importance of not isolating.
5. Maintain sources of reinforcement. COVID-19 has disrupted many of our existing sources of reinforcement (e.g., engaging in Greek life, attending a NCAA basketball game with friends, earning money working at a campus coffee shop). Find creative ways to derive pleasure, especially through activities that bring a sense of meaning and purpose. For example, developing new hobbies (e.g., biking, photography) might serve to reduce the reinforcement void.
6. Limit use of substances. College students with ADHD are at increased risk for substance use problems. The distress caused by the pandemic in combination with reduced opportunities for rewarding activities may make substance use (alcohol and cannabis in particular) more enticing for those who are particularly vulnerable. We recommend being mindful that despite liquor stores being classified as essential services, heavy use can actually impair mood and academic functioning (Meda et al., 2017).
7. Increase physical activity, especially outside. A significant body of research indicates that physical activity is beneficial for reducing inattention and anxiety and improving mood (Neudecker, Mewes, Reimers, & Woll, 2019). A sedentary lifestyle is therefore particularly problematic for college students with ADHD. Aiming for 7000 steps per day is a reasonable place to start. The old maxim, “What gets measured, gets done” suggests smartphone apps to track and plan physical activity may improve adherence.
8. Reduce procrastination. Rather than saying, “I will do that later”, attach a specific time/date target to each important task, and use a planner to indicate when you will work on each task. Divide larger tasks into smaller tasks and connect each task to a specific time/date in your planner. Be mindful of how you “advertise” the task to yourself. A script, “What is in it for me to do this now?” can be useful for framing tasks in a way which increases engagement.

The above represents only a few of many possibilities. Please consider replying to this blog with your own ideas about what might be beneficial to consider for college students with ADHD during the COVID-19 pandemic!

Citations

Jenness, J. L., Jager-Hyman, S., Heleniak, C., Beck, A. T., Sheridan, M. A., & McLaughlin, K. A. (2016). Catastrophizing, rumination, and reappraisal prospectively predict adolescent PTSD symptom onset following a terrorist attack. Depress Anxiety, 33(11), 1039-1047. doi:10.1002/da.22548

Lyall, L. M., Wyse, C. A., Graham, N., Ferguson, A., Lyall, D. M., Cullen, B., . . . Smith, D. J. (2018). Association of disrupted circadian rhythmicity with mood disorders, subjective wellbeing, and cognitive function: a cross-sectional study of 91 105 participants from the UK Biobank. Lancet Psychiatry, 5(6), 507-514. doi:10.1016/S2215-0366(18)30139-1

Meda, S. A., Gueorguieva, R. V., Pittman, B., Rosen, R. R., Aslanzadeh, F., Tennen, H., . . . Pearlson, G. D. (2017). Longitudinal influence of alcohol and marijuana use on academic performance in college students. PLoS One, 12(3), e0172213. doi:10.1371/journal.pone.0172213

Neudecker, C., Mewes, N., Reimers, A. K., & Woll, A. (2019). Exercise Interventions in Children and Adolescents With ADHD: A Systematic Review. J Atten Disord, 23(4), 307-324. doi:10.1177/1087054715584053