ADHD and Inequality: Theorizing a Dual Pattern of Diagnostic Pathways, Symptomatology, and Treatment

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ADHD

Author: Ruth Schlenker

ABSTRACT

First, I briefly review the inconclusive psychological literature about Attention Deficit Hyperactivity Disorder (ADHD)’s lack of diagnostic validity and heterogeneity to make the case that its diagnosis and interpretation are highly dependent on social context. Next, I theorize ADHD’s dual functions of performance enhancement for the more-privileged and social control for the less-privileged—and explain how ADHD’s naturalization as a “pathology” allowed for this dual function to be overlooked. I contextualize psychological debates about ADHD (namely its racial makeup, its under- or over- diagnosis, and its appropriate treatments) in terms of its historical and current role as a tool of social stratification and control. Finally, I problematize current approaches toward increasing parity of mental health access and call for a greater recognition in the medical literature of the social context in which mental disorders come to be known.

 

1. ADHD IN PRACTICE: HOW SCIENTIFIC IS IT REALLY?

ADHD, like all mental disorders, is in theory a biologically valid categorization. Indeed, ADHD is narrowly constructed in mainstream medical literature and has come to occupy a “hegemonic position in the modern child and adolescent mental health lexicon.”1 Underneath this veneer of scientific confidence, however, there are significant debates in the literature about the diagnostic validity of ADHD. Significant genetic,2 fetal-environmental,2  and comorbidity4 differences have been found between the inattentive and hyperactive-impulsive presentations of ADHD. Even assuming that despite these debates ADHD is still biologically valid, in practice, its patterns of detection are highly variable. Research has shown that “correlations between parent ratings, teacher ratings, and scores on objective measures of ADHD-characteristic behaviors are modest at best.”5

There are many potential reasons for this lack of consensus on what constitutes ADHD, and they all depend on social context. A “frog-pond” effect has been measured wherein chances of special education categorization increase with average levels of academic achievement in a given school.6 Although ADHD is not a learning disability, it adheres to similar patterns of context-dependency; a longitudinal study of one school district has traced a genealogy straight from manipulation of learning disability categories using test-score deflation to increase diagnoses to manipulation of the ADHD category as ADHD was popularized.7 The social context-dependency of ADHD can be clearly seen in studies that show that children with late birthdays are more likely to be diagnosed with and medicated for ADHD.8 Whether or not standardization of the ADHD diagnosis is theoretically possible, it remains clear that current practices in ADHD diagnosis operate far away from its objective conception in the medical literature.

 

2. SOCIAL MANIPULATION OF THE ADHD CATEGORY: TWO CONTRASTING MODELS

The social-context-dependency of ADHD is not randomly distributed. Inequalities in the wider society systematically permeate disparities in ADHD diagnosis and treatment. In this section I will draw on the psychological literature to theorize two broad archetypes of the function of an ADHD diagnosis: A more “positive” one for the performance enhancement of more privileged children, and a more “negative” one for the behavioral control of less privileged children. Each archetype has unique pathways to diagnosis, symptomatic clusters, and standard treatments.

Archetype 1: ADHD the High-Status Diagnosis

In the case of the school district referenced in the preceding study,9 there was an easily observable racial dimension to the manipulation of mental disorders: as racial parity in a given diagnosis increased due to pressure from racial equality groups, white children migrated to new diagnoses (such as ADHD) so as not to be in the same category as Black children. These new diagnoses were subsequently allocated more resources to appease white parents, while the old diagnoses lost status. Today, there is a stereotype about white parents getting their kids ADHD diagnoses as an excuse to give them stimulants for performance enhancement purposes. There is evidence for this—even abuse of stimulants is positively correlated with increased parental monitoring, which is in turn correlated with increased family wealth.10 Indeed, many studies show that white children are more likely to be diagnosed with ADHD.11, 12, 13 In fact, the assumption of racial disparity in ADHD diagnosis is so ingrained in the literature that it is stated in the DSM-V.14 All this evidence fits squarely within the perception of ADHD as a privileged disorder, one that coincides with my first archetype of ADHD-as-performance-enhancement. However, a recent meta-analysis15of 154,818 Black individuals from 1979 to 2020 found that Black people are just as likely to be diagnosed with ADHD as white people. Additionally, lower-class children are more likely to be diagnosed with ADHD than higher-class children.16 This complicates the ADHD-as-privilege stereotype and calls for a deeper look into the diverse social functions of ADHD.

Archetype 2: ADHD the Low-Status Diagnosis

Contrary to the stereotype that ADHD diagnoses are driven primarily by competitive white parents, teachers are actually more likely to initially suggest them.17 In cases where teachers rather than parents suggest an ADHD diagnosis, the behavioral control connotation of the suggestion becomes clear. This becomes problematic when teachers systematically perceive more- and less- privileged children differently. Teachers perceive both more inattentiveness and more impulsive-hyperactivity in lower-class children and Black children, with the racial perceptual difference still present even after controlling for class,18 and white teachers are more likely to perceive ADHD in Black boys than are Black parents.19 Additionally, many Black parents have negative perceptions of ADHD as a form of racial bias20 suggesting that teachers may be the main drivers behind the diagnoses of Black children specifically. Using this data, we can start to theorize distinct diagnostic pathways for children from more and less privileged backgrounds.

The symptomatology of ADHD also varies by race and class. Children with milder symptoms are more likely to be white and wealthier21, 22 while Black children are more likely to be co-diagnosed with Oppositional Defiant Disorder (ODD),23 which is interesting in light of research which finds that teachers often misperceive Black children as angry.24 This more negative characterization of ADHD which defies the contemporary ADHD-as-privilege stereotype is not new—it is grounded in some of the earliest conceptions of ADHD which called it a “defect of moral control” with symptoms of “cruelty; jealousy; lawlessness;  dishonesty; wanton mischievousness – destructiveness; shamelessness – immodesty; sexual immorality; and viciousness.”25

Along with distinctive diagnostic pathways and distinctive symptomatology of ADHD by race and class comes distinctive treatment methods. Class differences (as measured by type of insurance coverage as a proxy) in ADHD treatment are notable because they run contrary to the differences observed in mental disorders as a whole—while privately insured individuals are more likely to receive psychological services as opposed to medication only for mental disorders in general,26 the opposite trend is true in the case of ADHD.27 This observation further supports my theory that more-privileged individuals are diagnosed for school accommodations and/or stimulants in service of performance enhancement rather than for clinical interventions in service of behavioral control. The racial differences in ADHD treatment methods are even more well-researched: Black children are less likely to be prescribed stimulants,28 more likely to be prescribed antipsychotics29 (which is problematic considering the racist history of psychosis),30 and more likely to have discontinuous gaps in medication use.31

 

3. FUTURE RECOMMENDATIONS FOR RESEARCH AND PRACTICE

In the last section I presented two distinct patterns of ADHD diagnosis, symptomatology, and treatment that vary systematically by race and class. While all the studies referenced were themselves context-dependent, having different study populations, methods, etc., I hope that the preponderance of significant differences in the literature help make the case for further exploration of this difference and its integration into a nuanced biopsychosocial framework for understanding ADHD.

Right now, there is growing attention being paid to racial disparities in ADHD, but most of them rely on an acontextual medical model, supported by the continued assumption that minorities are simply underdiagnosed.32, 33  The “diagnose more minorities” approach seems to be what is taking place as ADHD diagnoses of minorities climb disproportionately to those of white people.34 I contend that these approaches are reductive—their lack of analysis on how ADHD diagnoses and treatments are applied differently towards more- and less- privileged individuals has the potential to harm minorities as diagnoses continue to climb. Here is just one example of the sociologically and historically uninformed rhetoric surrounding race and ADHD from a study I cited earlier:

Individual differences in ADHD and risk markers based on sex, ethnicity, and SES are likely to be important for providing a complete picture of interindividual heterogeneity within ADHD and for helping to explain heterogeneity in pathways to the disorder. Recent work suggests that there are also important ethnic differences in ADHD symptoms (Gingerich et al., 1998; Samuel et al., 1997). ADHD symptoms seem to be higher in African Americans compared with Caucasians (Cuffe, Moore, & McKeown, 2005; Epstein, March, Conners, & Jackson, 1998; Lee, Oakland, Jackson, & Glutting, 2008; Reid et al., 1998; Reid, Casat, Horton, Anastopoulos, & Temple, 2001; Samuel et al., 1998; reviewed by Miller et al., 2009), as are levels of aggression (McLaughlin, Hilt, & Nolen-Hoeksema, 2007). Although the structure of temperament (and personality) has been well validated and fairly invariant across cultures and ethnic groups in general population samples (Costa, Terracciano, & McCrae, 2001; McCrae et al., 2002), little work has examined the possibility that there might be ethnic differences in temperament traits in children with ADHD. Further, no work to date has examined ethnic differences in executive function in the general population or in children with ADHD.35

Nowhere is a single mention of the racism historically present in perceptions of aggression, measures of executive function, or at any other layer of analysis that may have influenced the results of these studies. Rather, an “objective,” hegemonic picture of ADHD as a biologically valid category (one that is simply measured rather than socially constructed by potentially biased agents) is maintained throughout.

There are also efforts to increase ADHD’s positive social connotations,36 efforts which look very similar to current activism surrounding Autism Spectrum Disorder (ASD). It is important to note that ASD is a predominantly white disorder37 and historically there have been tradeoffs between resources for more privileged diagnostic categories and less privileged ones (looking back to the longitudinal school district study referenced earlier).38 Thus, I fear that as these approaches continue to gain traction, there are two likely scenarios: Either Black people diagnosed with ADHD will fail to benefit from this approach, or as the diagnosis as a whole obtains a more positive connotation, Black people who would have gotten an ADHD diagnosis will instead be met with more stigmatizing diagnoses such as ODD or Bipolar Disorder. It is also possible that increasing positive social connotations of ADHD can only go so far, because there is significant progress to be made. Children with comparable symptoms who have been left undiagnosed with ADHD have been found to do better in school,39 parents treat children worse after they receive an ADHD diagnosis,40  and teenagers tend to find ADHD treatments undesirable irrespective of race or class.41, 42

As an alternative to the two monolithic approaches of “diagnosing more minorities” and “decreasing social stigma” critiqued above I propose a framework for both research and psychological practice that is more sensitive to potential differences in how these approaches are applied on a micro scale. This can be done through seeing research subjects and patients as individuals with complex histories rather than simply members of a diagnostic category or members of a certain social caste. This will allow us to question our assumptions about the immutable objectivity of ADHD with socially-aware data which may lead to new insights both within clinical practice and beyond.

 

CONCLUSION

It is important to note that the problem of racism and classism in psychology is not limited to ADHD. Rather, ADHD can be seen as a case study of the risks inherent in using an ahistorical medical approach as opposed to one informed by the oppressive past and present of disparities in mental health diagnoses along socioeconomic and racial lines. ADHD is a useful example because of its prevalence and its diagnostic flexibility, but this pattern exists in many diagnostic categories. Further research is needed to make transparent exactly how social stratification operates in different areas of the mental healthcare system. Until mental health diagnoses no longer entrench racism and classism, this research must be accompanied by advocacy and action.

 

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  42. This last point has important implications—up to this point I’ve characterized the first archetype of ADHD as “positive” simply because it was seen as having a higher desirability and social status relative to the second archetype. However, “performance enhancement” is not inherently positive and it is not necessarily distinct from “behavioral control” in the sense that performance is a behavioral difference. However, because of race- and class- stratification, the behavioral control of the less- privileged is likely less academic-performance oriented because these children are expected to maintain their lower societal positions rather than climb the educational and economic ladder.