The Case for Underdiagnosis
The question of under- or overdiagnosis of ADHD has long
been up for debate, particularly since diagnoses started spiking in the 1990s. CDC data from 2011 to 2013 puts the rate of
ADHD in childhood at 9. 5 percent—a number that is sustained
by white children, who are diagnosed at a rate ( 11. 5 percent)
that is significantly higher than that of their African American
and Latino counterparts ( 8. 9 and 6. 3 percent, respectively).
Critics and skeptics suggest that white children are being
overdiagnosed (and overtreated) for ADHD, but the data may
Morgan conducted a well-regarded 2013 study that looked
at more than 17,000 U.S. children. By the time the study’s subjects reached eighth grade, African American children were
69 percent less likely—and Latino children 50 percent less
likely—to receive an ADHD diagnosis than their white counterparts. A follow-up study, in 2014, found that the disparity
actually started earlier: Before they even entered kindergarten,
African American children were 70 percent less likely to be
diagnosed with ADHD than white children. Children whose
primary language was something other than English—a group
that includes many Latino children—were similarly
A study that came out last year may make the case for
underdiagnosis most decisively. Published in September 2016
in Pediatrics, it found that black children in the sample population showed symptoms of ADHD at a significantly higher rate
than white children, but were diagnosed much less often.
The disparities don’t stop at diagnosis. The 2016 study found
that, once diagnosed, children of color were much
less likely to take medication. Just 36 percent of black kids and 30 percent of Latino
kids who had been diagnosed with
ADHD were taking medication, compared to 65 percent of white children.
The 2013 study found similar results.
Claims of overdiagnosis weren’t
supported by the data, researchers
said. In the 2016 study, white children
who didn’t show ADHD symptoms
weren’t significantly more likely to be tak-
ing medication than similarly symptomless
black or Latino peers. “White children in general were not
significantly more likely to be taking medication,” said Tumaini
Coker, M.D., an associate professor at the University of Wash-
ington School of Medicine, and the author of the 2016 study.
“That really suggests to us that the disparities we see were
more likely from the underdiagnosis and undertreatment of
African American and Latino children—rather than the over-
diagnosis and overtreatment of white children.”
Inequities in health care—particularly mental health care—
aren’t new. In 2002, the Institute of Medicine released a report
entitled “Unequal Treatment,” which found similar racial and
ethnic disparities across the entire healthcare spectrum.
“Regardless of the condition you picked, you found disparities
at every level of care,” said Natalie Cort, Ph.D., a clinical
psychologist and teacher at William James College.
Undiagnosed physical conditions, like heart disease or di-
abetes, indisputably increase the risk of death, Cort said. But
disparities in mental health care can have more subtle—but
no less serious—consequences. “Mental health professionals’
misdiagnosis of minorities directly and indirectly contributes
to racial and ethnic minorities being disproportionately rep-
resented in the criminal and juvenile justice system,” she said.
She calls it the “misdiagnosis-to-prison pipeline.”
Missing the diagnosis is really just the start of the pipeline,
she said. When teachers see ADHD behaviors—particularly
those involving impulse control—without attributing them
to a neurological cause, they often interpret them as defiance.
Kids who are viewed as defiant or violent are labeled, said
Cort—even if they’re not accurately labeled with ADHD.
“He’s going to be labeled as a ‘bad kid’ who is going to get
suspended, and probably going to get expelled,” she said. “And
being suspended once or twice is highly associated with be-
coming involved in the juvenile justice system.” Studies have
estimated that up to 40 percent of inmates in the U.S. have
ADHD—a rate that dwarfs that of the general population.
Not every person who has ADHD but hasn’t been diagnosed
winds up in prison. But untreated ADHD has far-reaching
effects—on self-esteem, social functioning, career progress,
and overall happiness. Janel, who wasn’t diagnosed with inat-
tentive ADHD until her mid-30s, can attest to that.
Looking back, she recalls having symptoms her entire
life, but says that, without a diagnosis, she spent most of
her childhood wondering what could possibly be
going on. She couldn’t keep anything neat, no
matter how hard she tried, and was constantly
scolded for the “trail of things” she left in her
wake. Even though she did her homework, she
seemed to leave it at home instead of turning it
in. In school, detention was a frequent punish-
ment for talking in class, but Janel felt she couldn’t
stop herself. “It got really out of hand,” she said.
Her parents were frustrated—with her messy
room, her inconsistent grades, the constant calls from school.
“They sat and watched me do homework—helped me do
homework,” she said. “And now they’re getting called because
I haven’t been turning in homework?” They didn’t
Despite all the calls, however, the school never suggested
Janel be evaluated for ADHD—and no matter how often her
parents tried to get her on track, Janel continued to struggle.
“There was a lot of hiding,” she said. “It felt like there was
something wrong with me.”