In this MD Newsline exclusive interview with child and adolescent psychiatrist Dr. Johnny Williamson, we discuss ADHD as it relates to race/ethnicity and gender.
Why do Black children suffer more from ADHD than children of other racial/ethnic backgrounds?
Dr. Johnny Williamson
“One, I think that’s a great question. I think that the diagnosis of ADHD has been, in general, more likely underdiagnosed than overdiagnosed. And I think what we’re finding as we start to increase the awareness and understanding about this disorder, I think we’re starting to see more and more people who are open to considering the diagnosis, are aware of it, and that are far often seeking care or treatment for that.
Now the data are a bit complex. There are a number of surveys that look at a 5% or so increase in the rate of diagnosis for African Americans and a little bit less than that for Latino populations. It’s hard to know how accurate that is. I think that there’s also data in recent years that really show a level of underdiagnosis for the Latino, Black, and non-white populations.
And so, I think that we probably, on a prevalence basis, have more white individuals that actually are being diagnosed and have ADHD, but the question really gets to the percentage of the population. We’re starting to see a higher percentage in minority populations, but the answer as to why is one that’s a bit complex.
There are a number of things that I think go along with that. One, we have to remember that ADHD is a neurodevelopmental disorder. And so what I mean by that is it’s a diagnosis that’s made in relation to the neurological development of a child, adolescent, adult. And so, that neurological development is impacted by things that occur in the environment.
There’s certainly a genetic component and other pieces to that, but if you look at the issues related to adverse childhood experiences and the higher rate of those experiences in minority communities. If you take social demographics and the environmental impact of living in more impoverished areas, which is much more likely in minority populations. All those things will impact the neurological, emotional development of an individual.
And so, there’s a lot of evidence to support that adverse experiences growing up is a big part of it. There are things that are more concrete in the environment, such as issues with lead. The level of lead in the community, you know when lead was used in paints, it would chip off, get into the ground, and the water. [Because] lead is toxic to the brain, we get a set of behaviors that can come out of that that include symptoms of ADHD.
And that’s a more concrete example, but the other influences are really much broader than that. The best evidence I’ve seen suggests that some of the biggest impacts are, as a minority individual, the likelihood of living in an environment, physically and emotionally, that can be more traumatic, is a big part of that. I think as we delve into and investigate more, we’ll understand more broadly some of the other factors. But [lead] seems to be chief among them.”
Why do boys seem to suffer more from ADHD than girls?
Dr. Johnny Williamson
“It’s very clear by the data that we have that we’re certainly diagnosing boys more than girls. I think that when we look at ADHD, there are the problems with focus and attention, as a general category, and then there are the kind of behavioral pieces, the impulsivity, the hyperactivity, those externalizing behaviors.
One, externalizing behaviors are more common in boys, with or without ADHD. Additionally, as human beings, parents, teachers, community members, we are much more able to pick up on, identify, and address an externalizing behavior because it’s disruptive. Right? The teacher is conducting class, and someone’s out of their seat, they’re talking, that draws our attention and shows up on our radar much more readily.
The kind of oversimplified example is you have a hyper boy who’s running around and talking and not paying attention, where we think by the data that females actually, one, have less externalizing behaviors in general, but really do suffer from ADHD at a higher rate than we understand. However, their primary symptoms are the internal ones: focus and inattention.
So if she’s sitting there quietly, appearing attentive, but [her] mind is somewhere else—hard to track, hard to organize—to a teacher sitting there with 35 kids, that may not stand out as problematic behavior. It may show in grades and performance, but the likelihood of identifying that as something that would require or could benefit from medical intervention doesn’t happen as much.
And so, as such, I think that we’re identifying that inattentive subtype that happens more frequently in females less often than occurs, or at the very least, it tends to get picked up after a much longer period of time when that young girl’s intellect, other things seem to show that she’s significantly underperforming over time and an attentive parent, or teacher, or someone else might say, ‘hey, what’s going on here?’
Three, four, five years go by, and then they may present. The problem with that, of course, is that we don’t get those years back. And the impact on that learning, developing mind is at a bit of a loss of what that experience would’ve been had they been identified, diagnosed, and then provided effective treatment much, much sooner.
And so, I think the bigger part of this is one, just the natural externalizing behaviors, and then two, in the environment where these things are most often identified, we’re kind of cued to look for that externalizing behavior as opposed to the more internalized, lack of focus, disorganization types of symptoms.”
Responses have been condensed and lightly edited.