Racial Disparities in ADHD Care: How Clinicians Can Better Serve Patients

Research confirms that early identification and treatment of ADHD puts patients on the best possible path to wellbeing. At the same time, systemic inequities in healthcare are an unfortunate reality that disproportionately impacts Black patients and unnecessarily delays ADHD diagnosis and treatment. Clinician bias, structural racism, and community distrust of healthcare practitioners are all factors that perpetuate racial disparities in ADHD care. The roots of these issues are complex and the consequences severe.

Still, clinicians have the power to improve care for Black patients by taking the time to understand and mitigate barriers. Education and action are the foundation.

ADHD in Context: Unseen Factors in the Room

No two patients, even from the same cultural background, are alike in their medical needs. That said, Black patients are disproportionately impacted by the following factors and contributing health issues, which often go unnoticed or ignored but greatly impact outcomes.

Trauma and Poverty

Black individuals are more likely than white individuals to experience childhood adversity, and children who have these experiences are more likely to struggle in school and have emotional and behavioral challenges.¹ Black children are more likely to live in poverty and in disadvantaged neighborhoods, where poor access to quality foods and close proximity to facilities that produce hazardous waste increase health risks.^{2 3} Poor sleep quality is also linked to poverty.⁴ A patient who has experienced or is experiencing one or many of these factors can absolutely have issues with focus, attention, behavior, and learning — issues that mimic, aggravate, and/or overlap with ADHD.

ADHD Stigma

Negative attitudes toward mental health conditions and their treatment are prevalent in Black communities.⁵ Some individuals believe, for example, that ADHD isn’t a real diagnosis — that it’s been made up by white people to get Black children in trouble. This is a belief I’ve seen in my own practice.

[Read: Evaluating and Treating ADHD in African American Children — Guidance for Clinicians]

I was performing an ADHD evaluation on a young Black child whose teachers and school counselor — all white — suspected that he was showing symptoms. His rating scales indeed indicated that he had ADHD. The patient’s mother told me, a Black clinician, “You think like those white folk.” These negative attitudes can erect barriers around somebody who needs help — even if the news is coming from a clinician of the same racial or ethnic background as the patient. Some communities, in addition, may look to faith instead of the medical system to address and overcome mental health concerns.

Medical Mistrust and Misinformation

Black communities may fear the medical system — and with good reason. Their fears are the lasting legacy of past abuses by the medical system (the Tuskegee Study is a harrowing example) and ongoing medical racism that leaves Black patients with worse health outcomes than patients from other groups.⁶ One of the most common and pervasive myths I have to dispel for my patients is that ADHD medication causes children to become addicts. I’ve also heard families express fears that medication is a mind-control tactic.

Fear of Labels

Many Black individuals and families regard the ADHD label and other mental health diagnoses as the start of the end. Parents fear that their newly diagnosed child will be held back and targeted academically — beliefs that must be viewed from the context of the school-to-prison pipeline, which impacts Black students with disabilities more than other students.^{7 8}

Clinician Bias

Clinician bias can skew evaluation and treatment outcomes. Black youth, for example, are more likely to be diagnosed with disruptive behavior disorders like oppositional defiant disorder (ODD) and conduct disorder (CD) and are less likely to be diagnosed with ADHD.⁹ In my experience, I’ve seen these diagnoses given when ADHD doesn’t respond to medication as expected and when emotional dysregulation, including anger, is present. In other words, many clinicians think, “If we can’t get it right, then it must be ODD or CD.” Sadly, many patients spend years with inadequately treated ADHD when success is simply a matter of increasing, adjusting, or changing the medication for better symptom control.

[Read: Why We Need Clinicians of Color to Normalize ADHD in BIPOC Communities]

Clinician bias also affects how much a doctor invests in treating a patient, an issue that impacts Black patients the most, as doctors are more likely to describe Black patients with negative descriptors (e.g., “difficult,” “not compliant,” “agitated”).¹⁰ When this is the case, patients are cut off from options that can better treat symptoms and improve functioning and wellbeing.

Communication Styles

Some patients and families may communicate issues using a certain vernacular, colloquialisms, verbiage, and/or a dialect that clinicians may misunderstand or misinterpret. Without any clarifying follow-up, there could be a missed diagnosis or misdiagnosis.

Racial Disparities in Health Care: How Clinicians Can Improve ADHD Care

1. Identify your blind spots. We all have them, and it’s our responsibility as physicians to go out of our way to check them regularly in order to better address our patients’ needs. Implicit bias training can help you identify your blind spots. Take the free Implicit Association Test (IAT) to learn about your hidden attitudes and beliefs. As you learn about and acknowledge your blind spots, tell yourself before you start your workday, “I know I have biases, but I am going to go above and beyond for my patients to make sure I do my job correctly.”

2. Don’t be afraid to ask questions. Questions communicate interest, not ignorance. When you ask a patient about themselves, and how their identity and intersects with their health and wellbeing, it shows that you are paying attention to who they are and it builds trust.

3. It’s your duty to get information out of your patient. Recognize that patients may express health concerns in ways you’re not accustomed to hearing. A comprehensive clinical interview is vital for understanding and clarifying your patient’s concerns, including issues that may mimic or co-occur with ADHD. Rating scales alone won’t cut it. Also remember that patients often have to jump through several hoops to make medical appointments; no one shows up to an appointment (a costly one at that if they don’t have insurance or full coverage) because they feel like it. Think twice before you deem patients “noncompliant” or judge their motivations for being there. There are real concerns to be addressed, and it’s your job to uncover those needs.

4. Ensure all medical decision makers are in the room. In some families, a child’s grandparents — not their parents — may be the ones who ultimately decide on treatment. Take time to understand a patient’s family dynamics.

5. Help patients and families understand the benefits of an ADHD diagnosis. Parents should understand that ADHD is treatable, and that a diagnosis will allow their child to get the services to which they are entitled. Families should run to, not away from, special education services and their tailored resources. Explain to concerned parents that all educational services requiring funding — from gifted and talented programs to resources for students with disabilities — go through special education.

6. Obtain consent and ensure transparency. If you believe a patient will benefit from additional medical and wellbeing services, inform them and only put in an order after obtaining their approval.

7. Understand a patient’s circumstances and expectations. Do not assume that your approach, model, or ideas are the best fit. Really listen to what your patient identifies as their top issues, what they expect out of treatment, and what circumstances will allow them to pursue. Then devise a comprehensive treatment plan that covers those needs. Behavior parent training, for example, may necessitate an alternative approach if caregiver schedules and stressors interfere with the consistent application of positive reinforcement and discipline. No matter the plan, ensure that you, your patient, and other decisionmakers are on the same page.

8. Empower patients to advocate for their health. Most ADHD cases are treated by primary care physicians, but there are a host of providers — from nurse practitioners to psychiatrists — who can help. While insurance plans and financial circumstances may limit where patients choose to go, they should still be aware of these options. Comfort and compatibility are key when choosing professionals, so remind patients that there is nothing wrong with seeking second opinions. Often, the best way to find doctors — especially culturally competent providers — is by asking friends, relatives, faith and community leaders, and other trusted individuals for recommendations. BlackPsychiatryDirectory.com is a helpful resource.

9. Commit to ongoing education. As a psychiatrist, I consider myself a social scientist, and I invite all clinicians to take this approach. Be interested in people and cultures outside of your own. Books, news, films, television shows, and podcasts are all great ways to gain exposure to different cultures and identities.

Racial Disparities in Health Care: Next Steps

• Read: Why ADHD Is Different for People of Color
• Read: ADHD Clinicians Must Consider Racial Bias in Evaluation and Treatment of Black Children
• Read: We Need to Talk About ADHD Stigma in BIPOC Communities

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “Health Equity in ADHD: Addressing Racial Disparities in Diagnosis & Treatment” [Video Replay & Podcast #495] with Napoleon B. Higgins, Jr., MD, which was broadcast on March 7, 2024.

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