egregious historical wrongs in the field—and that makes it
hard for people to approach the field.”
The Frog Pond Effect
Years of formal and informal segregation, redlining, and other
discriminatory practices have led to vast disparities in the U.S.
school system—disparities that, again, hit children of color
“Children who are racial and ethnic minorities are more
likely to be exposed to poverty,” Morgan said. Wealthier
schools have access to better resources—meaning the achievement level is generally higher than it is at poorer, under-resourced schools. This plays into something called “the frog
pond effect,” which influences the likelihood that a child will
be identified for special education services.
There are two factors to the frog pond effect, Morgan said.
“One is the child’s own behaviors or academic achievement—
how he or she is doing in a classroom individually. But another
is the context in which the child is being evaluated.” That means
that in a school dominated by high-achieving kids, a child with
behavior or attention problems will stick out like a sore thumb.
But in poorer schools—those that are overcrowded, understaffed, and underperforming—a similarly struggling child
wouldn’t be as noticeable. In other words, Morgan said, where
the child is attending school matters when it comes to ADHD
diagnosis—even though, in a perfect world, it shouldn’t.
“From a clinical standpoint, it should be irrelevant,” he said.
“The disability criteria is set at the state and the federal level,
and those are the benchmarks which should be considered—
not how your school is doing.” But it plays a part anyway,
he said—and children at poorer schools pay the price.
Insurance also plays a role. Children of color are more likely
to have public insurance, Coker said, which can make getting
an ADHD diagnosis harder.
“If you’re dealing with Medicaid, you may need to use a com-
munity mental health center,” she said. “That waiting list is
really long—it could be months before you even get assessed.”
Behavioral therapy is hard to access under Medicaid, too,
The issues that she struggled with the most—keeping track
of homework, keeping her room clean, talking out of turn—
weren’t seen by her family as problems that warranted profes-
sional help. “That’s something I just needed to figure out and
get done,” she said.
Coker, who is black, and has twin sons diagnosed with
ADHD, said there’s also a perception in some communities
that “ADHD is a label that’s put on a child as a form of racism
or bias”—which can lead to parents rejecting the diagnosis or
refusing to accept treatment. “It’s hard to treat something that
you think is just put on your child because of the color of [his
or her] skin. And it’s hard to get family involved in the strate-
gies you’re using to deal with your symptoms.”
Janel’s older brother, for one, was upset when she shared
her diagnosis, telling her, “They’re just going to pump you full
of drugs.” She would be “zoned out,” he said, under the influ-
ence of medications that have “horrible side effects and health
His reaction isn’t uncommon—and it may not be unwar-
ranted. Though stimulants have been proven safe over the
long term, they’re not the only medication used to treat
ADHD—and the other options aren’t always as benign. Studies
have shown that children of color, including those with ADHD,
are more likely than their white counterparts to be prescribed
strong antipsychotics—even though the side effects can be
severe and dangerous.
“If you’re seeing little black children or little Latino boys
and girls as being potentially dangerous and violent, and you
have a drug that can help manage some of that behavior, then
you might reach for that drug,” said Cort. “Even though you
know that antipsychotics take years off your life.”
All in all, minority communities may have a right to be sus-
picious of the medical establishment, Cort said. “The history
is replete with minorities being deliberately harmed” by
researchers—the Tuskegee Syphilis Experiment, in which
African American men were intentionally denied knowledge
of and treatment for syphilis, is perhaps the most notorious
example. “The cultural mistrust is based on really, really
Dismantle bias. Tackling implicit bias is a
complex problem, since people who see themselves as tolerant often bristle at the suggestion
that they hold racial biases. “But implicit bias
does not mean you’re racist,” Cort stressed.
“It doesn’t mean you’re a bad person—it just
means this is what you’ve been exposed to.”
Accepting that everyone has unconscious
biases—and recognizing how they may affect
decisions—can help clinicians and teachers
treat children of color in a more equitable way.
“The more aware you are of it, the more you
have control over the ability to mitigate it,” she
said. Formal bias training can be critical.
Use better diagnostic tools. Structured diagnostic tools can also help combat bias, by making
the diagnostic process less susceptible to each
doctor’s unique (and possibly biased) interpretation of symptoms. “The American Academy of
Pediatrics (AAP) has a great toolkit online for
pediatricians to make the diagnosis and to think
about treatment,” said Tumaini Coker, M.D.
Have more invested doctors. Asking the right
questions is the most powerful tool clinicians
have at their disposal—regardless of the race
or ethnicity of the patient. “It’s one thing to
ask how school is going and be satisfied when
parents say, ‘Fine,’” Coker said. It’s another to
“get into the nitty-gritty of what ‘fine’ means,”
she said. “It may mean that they’re in detention,
or that they’re failing, or that they’re getting A’s,
but we don’t know if we don’t ask the difficult