Race, Ethnicity & Sexual Orientation

Race, ethnicity and sexual orientation may not be the first things that come to mind when you think about ADD, but no mental health condition–including ADD–can be accurately diagnosed or effectively treated without considering how race, ethnicity and sexual orientation come into play.

Risk of Mental Illness and Disparities in Treatment for Minority Populations

Racial, ethnic and sexual minorities are often more at risk of mental illness. While most research on discrimination and its effect on health has focused on single forms of discrimination, sociologist Eric Grollman reported in 2014 that adults who experience multiple forms of discrimination–the so-called “multiply disadvantaged”– are “more likely to experience major depression, poor physical health, and functional limitations” compared to singly disadvantaged and privileged adults. Multiply disadvantaged adults–including racial minorities, women, and sexual minorities–face such greater health risks “in part because of their disproportionate exposure to discrimination.”

Minority status may also factor into the type and quality of healthcare one receives. In 2003, researchers at the Center for Chronic Disease Outcomes Research described “extensive evidence” of racial and ethnic disparities in medical care received, which were “independent of clinical appropriateness, insurance status, treatment site,” and other clinical and socioeconomic factors. Researchers also noted that “African Americans and Latinos have been found to be less likely than Whites to receive guideline-adherent treatment and follow-up.”

The same holds true for lesbian, gay, bisexual and transgender (LGBT) individuals. A 2015 Kaiser Family Foundation report found that LGBT individuals face multiple barriers to accessing health services, including stigma, discrimination, violence and rejection from their families and communities, as well as gaps in insurance coverage, financial hurdles, and poor treatment from health care providers.  As a result, LGBT adults in the U.S. experience “higher rates of mental illness, substance abuse, and discrimination compared to heterosexual and non-transgender adults.”

Race/Ethnicity and ADD Diagnosis

There are significant differences in ADD diagnoses across racial and ethnic groups in the United States (see chart below). ADD diagnoses are higher among non-Hispanic whites than for minorities, even though actual prevalence is probably similar across all racial-ethnic groups.

Infographic_race and ADD prevalence_cropped

The differences in ADD diagnoses along racial lines may be explained in part by cultural factors that influence parents’ view of their children’s behavior. As psychologist Lauren Marie Haack  explains, available studies suggest that Latino children are at a great or greater risk of developing ADD, but their parents are much less likely to identify their problematic behavior. As a result, they are less likely to receive a proper assessment and treatment.

Parents may also not report ADD symptoms due to language barriers in both acculturated and non-acculturated immigrants, or limited knowledge about ADD. For example, researchers note that if a doctor asks the parents or child whether paying attention is problematic, “this may be perceived or misunderstood as a question regarding alertness or intellect and may contribute to a misdiagnosis.”

In order to bridge this gap, Haack and her colleagues tested the ADHD-FX, “a culturally sensitive assessment measure of functional impairment related to ADHD for diverse families.” Initial results indicate that the ADHD-FX is a “reliable, valid, and culturally appropriate measure to assess functional impairment related to ADHD” including academic challenges and difficulty with family relationships.

While factors related to race and ethnicity may lead to under- or misdiagnosis of ADD, institutionalized racism within the medical profession may also lead to misdiagnosis, inappropriate treatment and negative health outcomes. As clinical psychologist Eric Greene demonstrates in this case study, the “longstanding tradition” diagnosing and treating patients based solely on biological or psychological factors “runs the risk of oppressing patients further by denying the effects of their social context.” In this case, Greene describes an African-American boy who was misdiagnosed and treated for ADD when his symptoms most likely stemmed from the trauma and ongoing violence that he experienced during his childhood.

Access to ADD and other Mental Health Treatment

Even if there are culturally sensitive tools to diagnose ADD, racial minorities may face barriers to treatment due to a lack of health insurance, the high cost of care, and stigma against mental illness. For example, a review of studies that examined ADD diagnosis and treatment among Hispanics and African Americans found “under-use” of mental health services due to financial barriers to care, “cultural attitudes toward mental illness, and the effects of real or perceived prejudice and stigmatization.” Researchers added that “when stigma of mental illness is added to the challenges faced by racial/ethnic minorities or immigrant status, patients may be especially sensitive.”

Most recently, a study published in 2015 found that Hispanics in the United States face “many barriers to seeking and receiving treatment for mental health conditions such as ADHD.” Low incomes and a lack of health insurance limit access to quality care, while “language and cultural barriers keep some Hispanic patients from seeking treatment.” The study found that the importance of self-reliance, mental illness stigma, and misinformation about mental illness and treatment may have also prevented Hispanics from seeking ADD treatment.

Psychiatrist Anthony L. Rostain also published research in 2015, which focused on African Americans’ access to mental healthcare. Rostain found that they often do not receive care for conditions like depression and ADD due to a lack of health insurance and an inability to pay for mental health services. Rostain also attributes African Americans’ lack of access to care to stigma toward mental illness.