Diagnosing ADHD & ID in African-American Children
Danielle Leach, M.S.
Los Angeles, California
Prevalence of ADHD & ID in African-American Children
Attention Deficit Hyperactivity Disorder, often referred to as ADHD stands as one of the most commonly diagnosed disorders among children in America. Despite the significant amount of research conducted on ADHD surrounding diagnosis and treatment, there has been very little evidence that lends enough information to determine a definitive cause. To that end, many parents who are told that their child meets the criteria for the disorder, struggle with accepting the label of the diagnosis in the absence of an explicit cause or explanation as to how their child developed the disorder in the first place.
The rate of diagnosis of ADHD in children has been steadily on the rise over the past decade and continues to rise simultaneously as the criteria for diagnosis of ADHD becomes looser with the release of each new edition of the DSM (Diagnostic & Statistical Manual for Mental Disorders) (Joyce Cheng, "Arguments about Whether Over-diagnosis of ADHD is a Significant Problem"). This increase can be explained by a number of contributing factors, including the following: (1) over-diagnosing (2) lack of continuity of care (3) loose criteria (4) increasing consumer demand and (5) clinician bias (Joyce Cheng, "Arguments about Whether Over-diagnosis of ADHD is a Significant Problem").
Matched with the overall prevalence of ADHD diagnosis in children in America stands a higher prevalence of ADHD with hyperactivity subtypes diagnosed in African-American children (Root & Resnick, 2003). This raises the question as to whether ADHD in African-American children is being over-diagnosed by clinicians or if more and more children are actually presenting with symptoms that meet criteria for the diagnosis. The complexity in resolving such problem is predicated on the reality that diagnosis of mental health problems in a marginalized population is highly likely related to the systemic pressures put on teachers and school psychologists to discriminate against children of color, leading to classroom segregation and over-placement of African-American children in special-education classes.
The higher prevalence of ADHD in African-American children still speaks to a bigger problem in our nation, with an underlining reality that more children are diagnosed with ADHD in America than any other country (Joyce Cheng, "Arguments about Whether Over-diagnosis of ADHD is a Significant Problem"). Despite our nation’s reputation of being a leader in health and education, many of its citizens are falling victim to the pitfalls of democracy and politics, as they remain the driving mechanisms by which these systems operate. The current rate for ADHD diagnosis in America stands at 11% and continues to rise as more and more generations of children are funneled through the system (Joyce Cheng, "Arguments about Whether Over-diagnosis of ADHD is a Significant Problem").
So while causes of ADHD in children remains unknown, there are several hypotheses for how African-American children are at a higher risk for attaining the disorder. One possible explanation for the higher prevalence of ADHD in African-American children has been linked to environmental influences, namely socio-economic status of the family to which the child is directly influenced by (Joyce Cheng, "Arguments about Whether Over-diagnosis of ADHD is a Significant Problem"), making children who attend schools in neighborhoods with families represented by low socio-economic status (SES) more susceptible to the diagnosis. Taking a closer look at the diagnostic criteria for ADHD, one can understand how a child’s socio-cultural environment can be a contributing factor to shaping the onset of the disorder. The DSM states that a child has to endorse either 6 of the Inattention symptoms and/or 6 of the Hyperactivity symptoms for a period of 6 months in order to meet the diagnostic criteria for ADHD (Diagnostic and statistical manual of mental disorders: DSM-5, 2013, pp. 59-60). The symptoms must begin onset before age 12, be evident in two or more settings, and cause significant distress or impairment in functioning (Diagnostic and statistical manual of mental disorders: DSM-5, 2013, pp. 59-60). Some of the symptoms included in this criteria that could possibly be explained by socio-cultural and environmental factors include the following: difficulty in sustaining attention on tasks; difficulty with organizing tasks; avoids participating in tasks that require sustained mental effort; often loses things required to complete tasks; forgetful and easily distracted; being fidgety; leaving seat when expected to; unable to play quietly; unable to sit still; excessive talking; blurting out answers and not giving others time to complete their sentences; interrupting others; and having difficulty waiting turn (Diagnostic and statistical manual of mental disorders: DSM-5, 2013, pp. 59-60).
So in essence, what may by perceived by one group of people as disruptive, inappropriate, and abnormal behavior, could simply be a representation of cultural differences between ethnic racial groups, high influenced by their socio-cultural environment in which they live in. Interpretation of these behavioral characteristics are predicated on whether or not the person making the observation views the behavior as a function of one’s culture and environment as opposed to an inherent trait that underscores a specific deficit in the individual.
The fact that there’s a higher prevalence of ADHD diagnosis in low SES schools (Root & Resnick, 2003) speaks more to racial disparities than it does income status, given that the majority of low SES families are represented by people of color. Within poor families, exists issues surrounding poor nutrition and diet which could also provide possible explanations for the hyperactivity and inattentiveness. Essentially, it would be very difficult for anyone to remain attentive and productive at work or school when there are concerns about one’s health and safety that linger constantly in their minds. Nevertheless, it is one’s cultural adaptation to these socio-economic problems linked to racial oppression and discrimination that also have a detrimental impact within every individual who is affected.
More specifically, within the African-American culture, it isn’t uncommon for a person to finish another person’s sentence while they are speaking, especially when the person speaking is having trouble formulating the words they’re trying to say. This linguistic difference seen within the African-American culture may come off as strikingly problematic in the context of a culture that highly values verbal ability defined by “appropriate” pronunciation, articulation, and subject-verb agreement. Even within many African-American churches, you will find a style of worship that is very different than what you will see in white churches where the congregation will interact with the pastor by “blurting out” phrases like, “Yes!” “Preach!” “Praise God” to encourage the pastor to continue preaching and serves as minimal encouragers to let the pastor know that the church is following what he’s saying. These slight nuances in communication speak to cultural differences between Blacks and Whites that are not yet recognized and understood by mainstream culture, especially as it relates to the educational school setting. Because Blacks within American society are seen as a numerical minority group, a lot of behaviors that are normal within this subgroup are pathologized within the greater context of the dominant culture.
As a result, the diagnostic criteria and labels of ADHD in the DSM are problematic for many clinicians because they are unclear and confusing (Root & Resnick, 2003). You can take 10 different clinicians, hand them one African-American child, and they will all come up with 10 different diagnoses. This is mostly due to the fact that the criteria in the DSM is very vague, too broad, and all-encompassing. Clinicians are met with a very challenging task of assessing pathological symptoms in clients that cause distress for the individual, but with respect to the diagnosis of ADHD, the symptoms are more a distress for the people in the individual’s life (namely the teachers and parents) than they are for the child themselves.
Dr. Umar Johnson, a Certified School Psychologist in the state of Pennsylvania who specializes in early childhood assessments indicates that there is a very high prevalence of ADHD diagnosis in African-American boys in public schools that is mostly linked to environmental causes, that he has coined, “Ain’t No Daddy at Home Disorder.” In his book, “Psycho-academic Holocaust: the Special Education & ADHD Wars against Black Boys,” Dr. Umar emphasizes the importance of the role of positive male role models and having a father figure to the healthy development of a child’s life (Johnson, U., 2013). The numbers of African-American children being raised in single parent households is alarming and has become a topic of increasing concern for change agents within the Black community.
Disproportionate and Over-representation of African-American Children in Special Education
Alongside the over-representation of ADHD in African-American children sits a disproportionate representation of Intellectual Disability (ID) diagnoses in African-American children. Despite studies with attempts to disprove the over-diagnosis of ID and ADHD in African-American children (Norman, Staff, Hillemeier, Farkas, & Maczuga, 2013), research has shown that African-American students are being diagnosed with an intellectual disability at a right that is twice as high than White students (Gentry, "Disproportionate Representation of Minorities in Special Education - How Bad?", 2009). As a result, the similar questions relating to the over-diagnosis of ID in Black students, much like ADHD arise.
Under Section 504 of the 1973 Rehabilitation Act, children have the right to be afforded a quality and equal education (Root & Resnick, 2003) Under this Act, students should receive a multidisciplinary diagnosis and be afforded an appropriate individualized education plan (Root & Resnick, 2003). Despite legal regulations to enforce equality in education for African-American students, they are still met with challenges of racial disparity and discrimination in the educational school setting.
Over-representation of African-American students with intellectual disabilities has been attributed to: the classroom environment, family and environmental stressors, characteristics of the student, bias in standardized testing and curriculum, and teacher perceptions and attitudes (Gentry, "Disproportionate Representation of Minorities in Special Education - How Bad?", 2009). The most important and distinguishing factor that concerns many Black affirming clinicians is the biases presented in standardized testing and curriculum. In taking a deeper look at the disproportionality of African-American students in special education, test bias stemming from language barriers and economic disparity and disadvantage appears to be the most influential (Skiba, et al., 2008)
Problems with Diagnosis
Operationally Defining Intelligence and ADHD
The problem with diagnosis of ADHD and ID (Intellectual Disability) in children is rooted in the way in which the two are defined and measured. The two constructs are operationally defined in the context of a society that has a long history of racial oppression and discrimination. On one hand, being able to identify and define a given problem in society can be beneficial, pointing us to possible solutions for how the problem can be fixed; but on the other hand, the way in which a problem is defined can cause more harm than good to every individual affected by the problem. With respect to the current diagnostic criteria for ADHD and ID in the DSM, it is very clear that there is a system designed to separate a group of individuals who deviate from the norm. So at the end of the day, it doesn’t matter how or why they are different; what’s most important is that they are different and their difference is essentially causing a problem to society. Instead of appreciating the differences in individuals, we’ve become attuned to pinpointing and labeling those differences, putting those who are significantly different and don’t fit into society’s standard of normal in a dehumanizing box of their own.
Methods of Diagnosis
The method in which ADHD and ID are diagnosed speaks to why so many children, specifically African-American children meet the diagnosis. Efforts to make diagnosis more valid, reliable, and fair point to the need for differential diagnosis (Warner-Metzger & Reipe, "Disruptive Behavior Disorders in Children and Adolescents", 2013). So essentially, in terms of diagnosing ADHD, there needs to be a more defined way of interpreting and understanding behaviors presented by African-American children in classrooms. Before making a diagnosis of ADHD-hyperactivity subtype to a child who seemingly meets the diagnosis of ADHD as defined by the DSM 5, a well-trained clinician should assess whether there are instances where the child is able to sit still and complete tasks and under what circumstances as opposed to only looking for instances when the child is having difficulty sitting still, because there is a distinct difference. It could be that the child is able to sit for long periods of time and attend to a task in an environment that is supportive of his learning style when he is given a task that the child finds meaningful and enjoys. The expectation of discipline for children to sit for a lengthy time in a classroom may be unrealistic for most children who appreciate interactive and engaging activities that include physical movement.
Likewise, instead of giving a child an intelligence test, like the WISC, which was originally normed on a group of White children, to assess their intelligence, clinicians should utilize culturally sensitive measures that accurately measure cognitive ability as opposed to verbal ability, which in part is biased toward European English speakers. Although many African-American children are taught English in their family household and in the schools, clinicians must be mindful that there still exists a language barrier for many African-Americans, much like there is for immigrants to whom English is their second language. As an African-American, I can assert that speaking “proper English” comes as a challenge for many African-Americans, as it still remains the language of our oppressor and a tool used to further oppress a group of people who come from a lineage of slaves where English was not their native language.
Effects of Diagnosis
The impact of mis-diagnosis of ID and ADHD in children can have very profound effects. Restricting a student to a certain academic setting, such as special education classes, can limit his or her learning potential making it problematic for the developing child to compete in a global marketplace (Codrington & Fairchild, 2012). More specifically, the placement of students in special education can lead to the reverse effect than initially intended, causing them to adopt similar characteristic of children with disabilities which could lead to an increase high school dropouts, police arrests, decreased employment, and a lesser chance of independent living (Codrington & Fairchild, 2012). Dr. Umar Johnson speaks on the school to prison pipeline in his book, “Psycho-academic Holocaust: the Special Education & ADHD Wars against Black Boys,” suggesting that public schools are designed to weed out African-American boys by labeling them with ADHD, ODD, and other conduct disorders, which inevitably shape the child’s identity (Johnson, U., 2013). So essentially, these special education classes becoming a “holding cell” for the African-American students that many culturally incompetent teachers have wrote off as bad apples.
Other effects of over-representation of African-American students in special education include lesser academic expectations and stereotyping (Edwards, O.W., 2006). When African-American students are labelled learning disabled, they feel a sense of lowered self-esteem (Hamilton & Astramovich, "Counseling Children with ADHD: Three Focus Areas for Professional Counselors"). A threat to one’s self-concept and identity will inevitably affect the way in which they are perceived by others in the world and ultimately determine their place in society.
Reconceptualization of ADHD and IDD in African-American Boys
Interdisciplinary Approach to Diagnosis
Considering the issues with bias in testing and assessment, leading to an over-diagnosis of ADHD and ID in African-American children and disproportionality of African-American students in special education classes, it is likely that an interdisciplinary approach to diagnosis is warranted to ensure proper and fair treatment of African-American students in the classrooms. This entails having a consultation with medical doctors, pastors, community leaders, and Black affirming mental health advocates before a permanent label of ADHD or ID are assigned to a child. As it stands, a psychologist can diagnose ADHD, a disorder that is considered to be a deficit in one’s brain, without the aid of a physician or medical doctor. Much like depression is understood as a deficit in serotonin in the brain and can be diagnosed without a CAT scan of the brain, the same ill-informed practice is happening with mental health diagnoses rooted in one’s genetic and biological makeup.
Teacher training, behavior management strategies, early prevention, less bias testing, increased family and community engagement, and policy reform are all likely solutions to preventing or reducing over-diagnosis of ADHD and ID (Skiba, et al., 2008). If research has already found that clinicians are biased in their assessment of psychological researchers, teacher training in cultural diversity may prove to be a likely solution. However, cultural diversity training isn’t the end all be all, because with training also comes the threat of external socialization that the teachers are affected by in a broader context. So teachers and clinicians can go through hours of cultural diversity training to make them more aware of the differences in culture between students of various racial ethnic backgrounds, but the training may not be as effective in curbing their inherent bias against children of color all together – given the overarching influence of a racially oppressive society propagandized by the media and politics.
Therefore, advocacy on behalf of teachers, psychologists, and community leaders is paramount to reducing the likelihood of over-diagnosis and over-representation of African-American students in special education classes (Codrington & Fairchild, 2012). While teacher training is useful, it isn’t sufficient.
Addressing test bias in a more concrete manner also plays an integral role in preventing over-diagnosis. Clinicians should ask the following questions: Do tests have high construct validity? Do they measure what they purport to measure? (Reynolds & Suzuki, 2012). Many researchers and clinicians alike are advocating for the development of testing and assessments that are more culturally sensitive and appropriate for the demographic they are being used on (Reynolds & Suzuki, 2012).
The No Child Left Behind Act puts the responsibility on the teachers to ensure their students are grasping the material (Land, M.Y, 2015). If students aren’t meeting the curriculum standards set by the school district, then it becomes the teacher’s job to ensure that their student receives the proper educational plan that supports their style of learning. The challenge comes in developing an educational plan that addresses any learning deficits the child may be experiencing while at the same time, making sure the child isn’t being discriminated against by being placed strategically in segregated classrooms that make them feel inferior, unequal, and less intelligent. So ultimately, school psychologists are tasked with the responsibility of reducing the number of African-Americans over-represented in special education classes ("Racial and ethnic disproportionality in education", 2013).
Issues surround blaming the victim versus blaming the system arise when attempting to develop solutions to the problem of over-representation of African-American children in special education classes ("Attention Problems: Intervention and Resources", 2015). We live in a society that promotes freedom of individual choice and responsibility in the face of systemic oppression and discrimination. Finding a balance between the two can be quite alarming and perplexing.
Overall effective solutions to curbing the disproportionality problem in public schools involve a systemic approach that include the following: Getting family involved in prevention and intervention (Carr, A., 2009); Multi-cultural training and education for educators working with African-American youth (Ford, B.A., 1992); taking a strength-based approached in promoting achievement, ethnic identity, and skill-building in African-American youth (Ford, D.Y. "Counseling Gifted African American Students: Promoting Achievement, Identity, and Social and Emotional Well-Being", 1995); and more importantly, teaching through learning styles i.e. expressive arts, poetry and music, drama, puppetry, writing, and drawing (Ford, D.Y. "Counseling Gifted African American Students: Promoting Achievement, Identity, and Social and Emotional Well-Being", 1995)
Copyright Danielle Leach 2017 All Rights Reserved
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