Special Considerations

Even though ADHD is one of the most commonly diagnosed psychiatric conditions of childhood and adolescence, a child’s chances of being diagnosed vary considerably across gender, race, class, ethnicity, and socio-economic patterns . For example, White children are more likely to be diagnosed with ADHD than Hispanic and Black children (Danielson et al., 2018). T here are gender disparities, as well, with males diagnosed at a rate roughly twice that of females (Xu et al., 2018). This over- and underrepresentation of groups regarding ADHD significantly impact adult outcomes and one’s quality of life.

Impact of Caregivers Lived Experiences

Unequal patterns of diagnosis may reflect the unique experiences of caregivers from historically marginalized backgrounds in terms of how they engage with the healthcare system and receive a diagnosis for their children. The diagnosis of ADHD among children and adolescents, which varies by gender, race, class, ethnicity, and sexual orientation, is paradoxical to what a stratification lens would predict about groups historically situated lower in social hierarchies. Using the stratification lens, marginalized groups are predicted to experience higher rates of psychological disorders (Rosenfeld, 2012). These unequal patterns of diagnosis may reflect the unique experiences of families from disadvantaged backgrounds in terms of the  sociocultural meanings that clinicians, caregivers, and children of diverse identities attach to ADHD-related symptoms (Acri & Bornheimer, 2021; Khan & Secinti, 2020).

Prior research suggests that, compared to White families, Black families are less likely to have heard of ADHD; moreover, they are less likely to communicate with their providers about ADHD and tend to be less familiar with the biomedical framework for ADHD etiology, diagnosis, and prognosis (Simoni & Drentea, 2016). These differences are thought to contribute, in part, to well-documented delays in time to diagnosis for mental health conditions, including ADHD (Morgan et al., 2013). Receipt of an ADHD diagnosis is also thought to depend on the structural systems that sort children into different categories of disability and opportunities for service (Morgan et al., 2013). For instance, socially disadvantaged children may be assigned disability classifications that perpetuate their disadvantage (Fish, 2017). Meanwhile, socially advantaged parents can provide more significant opportunities for these diagnostic classifications to secure accommodations and resources (Blanchett, 2010).

Some scholars argue that a mutually constitutive lens, consistent with intersectionality theory, may be more appropriate for understanding differential diagnosis rates and underexplored, dynamic gender/race/class/ethnicity relationships in ADHD diagnosis. An intersectional approach to ADHD diagnosis could therefore consider how factors such as sexual orientation, gender identity, and discrimination intersect with race, class, and other social identities to shape patterns of diagnosis and access to care for youth with ADHD (Russell et al., 2018). It is also essential to consider the role of sociocultural meanings in shaping diagnostic patterns, as the diagnosis is a social process situated within a context of social relationships, interactions, and sociocultural meanings in which patients, caregivers, and clinicians are enmeshed (Coulter et al., 2018; Hsieh et al., 2020).

The following examples demonstrate the complex and multifaceted factors that can influence the diagnosis and treatment of ADHD. These examples highlight the importance of considering a range of social, cultural, and historical contexts in understanding patterns of diagnosis and care. Examples include:

• A non-Hispanic Black child may be more likely to receive an ADHD diagnosis than a Hispanic or non-Hispanic White child, even though historically, Black children have been situated lower in social hierarchies than White children (Morales & Shafer, 2019).
• A child from a low-income family may be more likely to receive an ADHD diagnosis than a child from a high-income family, even though traditionally, higher-income families have been situated higher in social hierarchies than lower-income families (Classen & Dunn, 2019).
• A clinician may hesitate to diagnose a child with ADHD because their behavior is seen as normative within their cultural context. In contrast, another clinician may be more likely to diagnose the same child with ADHD because they view the behavior as deviant (Kwok et al., 2011).
• A caregiver may be more likely to seek a diagnosis of ADHD for their child because they believe it will provide access to educational resources and accommodations. At the same time, another parent may avoid seeking a diagnosis because they believe it will label their child negatively or lead to over-medication Olfson et al., 2015).
• LGBTQ+ youth may be more likely to experience rejection or discrimination from healthcare providers or family members, affecting their willingness to seek help or disclose symptoms (Coulter et al., 2018; Hsieh et al., 2020).
• LGBTQ+ youth may have different experiences with gender and sexual identity development that can influence how they perceive and express ADHD-related symptoms (Kuperminc et al., 2014).
• Transgender youth of color from a low-income background may face multiple barriers to diagnosing and treating ADHD, including discrimination from healthcare providers, a lack of access to healthcare resources, and a limited understanding or acceptance of their gender identity and expression (Russel et al., 2018).
• Conversely, White cisgender youth from an affluent background may have greater access to resources and support but may still face stigma or misunderstanding about their symptoms and diagnosis due to societal beliefs about gender and ADHD (Russel et al., 2018).

Impact of Clinician’s Lived Experiences

Diagnostic patterns of ADHD may also reflect how clinicians, caregivers, and children of diverse identities understand and respond to ADHD-related symptoms and the broader sociocultural messages about them. Diagnostic disparities can occur from educators’ overreliance on subjective views, cultural stereotypes, and heteronormative lenses. These factors can contribute to bias in diagnosis referrals. For example, misunderstandings and behavior-based conflicts in school can also stem from gaps in cultural awareness due to disproportionate student-teacher racial/ethnic demographics. Bias, stereotypes, and discrimination in school can lead to student disengagement and negative academic persistence. These traits are often misidentified as symptoms of ADHD, which in many cases, leads to the student not getting the proper classroom attention or accommodations they need (Bergey et al., 2023).

In the Classroom

To illustrate the unequal patterns of diagnosis and the impact of caregivers’ and clinicians’ lived experiences, let us explore the stories of Simone (she/her) and Anne (she/her), two female middle school students. Simone is a Black child, and Anne is a White child. Both struggle with attention issues that impact their learning and are suspected by their teachers of needing special education support.

Simone (she/her). Her caregivers are unfamiliar with ADHD and have limited access to medical providers. They do not pursue a medical diagnosis, which leads her teachers to consider an Emotional Behavioral Disability (EBD) evaluation. The resulting special education services are drastically different for each child based on a caregiver’s understanding of ADHD and access to medical services. The EBD label often leads to segregation in special EBD classrooms or even more restrictive settings, with lower chances of high school graduation and a greater possibility of entry into the juvenile justice system. Educators in such settings often focus on modifying behavior rather than addressing learning or dealing with undiagnosed underlying disabilities or mental health needs.

Anne (she/her). On the other hand, Anne’s caregivers, who are familiar with ADHD, contact their medical provider to evaluate Anne. They return a few days later with an ADHD diagnosis. As a result of the medical diagnosis, Anne’s teachers move forward with a special education evaluation that focuses more on Other Health Disabilities (OHD), and she receives more inclusive support in the general education classroom. Thus, due to systems of oppression, educational inequalities are perpetuated and, at worst, the school-to-prison pipeline (see Chapter 7 for more information). A diagnosis may thus hold drastically different consequences for children from socially disadvantaged versus advantaged backgrounds.

A Way Forward

As a codification of beliefs within societal institutions, an ADHD diagnosis is a cultural, social, and behavioral phenomenon (Conrad & Barker, 2010) shaped by a complex array of underexplored social practices, constraints, and cultural meanings (Tseng, 2021). As we will learn in the next section, these unequal patterns of medical diagnosis directly impact identification and support in schools. An intersectional perspective on ADHD diagnosis could help identify and address these complex and intersecting factors to promote more equitable access to care for all youth with ADHD, regardless of their social identities or backgrounds.