Special Education Opinion

Diagnosing ADHD Is Hard. Here’s What Teachers Need to Know

Certain groups of students are vulnerable to being over- or underdiagnosed with ADHD
By Evelyn Polk Green — July 13, 2022 5 min read
Conceptual illustration of silhouetted children distorted by bias
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The chances are high that at some point in your teaching career, you’ll be asked to fill out an assessment (or many) for students suspected of having attention-deficit/hyperactivity disorder, or ADHD.

Most diagnoses require observational data of a student’s behaviors in different settings, such as at school and at home. But these observations are subjective and vulnerable to biases. An increasing number of studies show that certain groups of students are either over- or underdiagnosed with ADHD due to misconceptions about the disorder and differences by gender and race.

An estimated 6.1 million children in the United States have been diagnosed with ADHD. Millions more children with the disorder are surely left undiagnosed. Early intervention is so crucial for success down the road, at home and at school.

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It is important that teachers—who play a key observational role in ADHD assessments in a school setting—understand that many factors can play into a diagnosis and how racial, gender, and age biases can affect those factors. It is equally important that school systems provide educators additional support through more objective testing measures, many of which already exist.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines ADHD as a neurodevelopmental disorder characterized by persistent patterns of inattention or hyperactivity to the point where they interfere with development and daily functioning. Common symptoms are a lack of impulse control, restlessness, daydreaming, disorganization, forgetfulness, and poor attention to detail. While many of these behaviors can be attributed to typical child development, a key difference in a child with ADHD is they struggle with the same problems repeatedly, regardless of consequence or incentive.

Of course, many of these same symptoms are common with other disabilities, including anxiety disorders, obsessive-compulsive disorder, and autism. External factors like a lack of sleep, an unstable home life, stress, and trauma can also produce these symptoms.

Put all those factors together, and it can be difficult to distinguish ADHD from other issues initially.

When people think of a child with ADHD, they probably envision a child with boundless energy, constantly moving and talking, disruptively jumping from task to task. While these are classic signs, they do not paint a complete picture of ADHD and lead to the underdiagnosis of female students and the overdiagnosis of younger students.

According to the Centers for Disease Control and Prevention, male students are more than twice as likely to receive an ADHD diagnosis than female students. This is because ADHD symptoms often present differently between genders. ADHD is typically defined by three categories of behavior—hyperactivity-impulsivity, inattention, and combined. These behaviors are a common display of hyperactivity-impulsive type and are more often, but not exclusively, seen in male students.

Across genders, all three behavior types show up very differently. For example, hyperactivity-impulsivity in females often deals with difficulties in regulating emotion and can lead to difficulties forming social relationships with their peers. Females are also more likely to display inattentive-type behaviors such as distractibility, forgetfulness, inattention to detail, and disorganization. Because inattentive behaviors are often less overtly disruptive than hyperactive-impulsive behaviors, they are often overlooked.

Where girls are less likely to be diagnosed than boys, younger students are far more likely to be diagnosed than their older classmates. A recent meta-analysis of 19 studies in 13 countries covering more than 15.4 million children concluded that children whose birth date puts them on the younger side of their age-based cohort in school are considerably more likely to be diagnosed with or medicated for ADHD than their older peers. The pace of child development is very rapid, especially in the early years, so students who are months younger than their grade-level peers will display marked differences in behavior, especially when it comes to impulse control and activity levels.

Implicit bias can also hinder a diagnosis for students of color.

In both instances, children who go undiagnosed develop coping skills that then mask their symptoms. Critics of ADHD use these studies to argue that the diagnosis of ADHD is a sham, but this disparity is actually the result of emotional immaturity in younger children.

Implicit bias can also hinder a diagnosis for students of color. It’s an uncomfortable fact that everyone brings certain biases to their worldview. Our personal experiences, cultural messaging, and exposure to different people and ideas shape our judgments, for better or worse, and we may not know we have these implicit biases.
While these types of judgments are not maliciously intended, they can have a disproportionate effect on students of color. A 2013 study found that nonwhite students were 46 percent to 69 percent less likely to receive an ADHD diagnosis than their white peers. Follow-up studies as recently as this year have continued to confirm these disparities. In fact, students of color are more likely to be labeled with conduct disorder or oppositional defiant disorder (ODD) for behaviors that are labeled as ADHD in white students. Additional hurdles like higher rates of poverty, less access to health care, and cultural stigmas towards mental health within communities of color compound the problem.

The reality is that diagnosing ADHD is hard. With so many age-related and developmental questions at play in competition with our own biases, nothing is more important to the future of ADHD diagnosis than the widespread adoption of objective testing measures.

To get to an accurate (and unbiased) diagnosis, educators should use computer-based tests. These objective tools are already used by many clinicians who offer ADHD testing and diagnostic services, and the data generated serves as a valuable supplement to observational assessments, aiding behavioral health professionals in determining the best course of action. Tests that are cleared by the Federal Food and Drug Administration and can measure all three core symptoms stand to provide the largest benefit to clinicians and schools.

As our children face yet another year impacted by the pandemic, isolation, and remote learning, they are staring down the barrel of serious developmental challenges uniquely associated with growing up in this uncertain time. This is why now is a critical time for improvements in the assessment and diagnosis of ADHD and other developmental disorders so that we can get students the services they need to navigate this unprecedented era.

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