Underdiagnosed and undertreated, young Black males with ADHD get left behind

Reviewed by Danielle Ellis, B.Sc.Nov 9 2023

As a kid, Wesley Jackson Wade should have been set up to succeed. His father was a novelist and corporate sales director and his mother was a special education teacher. But Wade said he struggled through school even though he was an exceptional writer and communicator. He played the class clown when he wasn't feeling challenged. He got in trouble for talking back to teachers. And, the now 40-year-old said, he often felt anger that he couldn't bottle up.

As one of the only Black kids in predominantly white schools in upper-middle-class communities — including the university enclaves of Palo Alto, California, and Chapel Hill, North Carolina — he often got detention for chatting with his white friends during class, while they got only warnings. He chalked it up to his being Black. Ditto, he said, when he was wrongly arrested as an eighth grader for a bomb threat at his school while evacuating with his white friends. So he wasn't surprised that his behavioral issues drew punishment, even as some of his white friends with similar symptoms instead started getting treatment for attention-deficit/hyperactivity disorder.

"Black kids at a very young age, we start dealing with race, we have a lot of racial stamina," said Wade, who now lives outside of Durham, North Carolina. "But I didn't understand until later on that there was probably something else going on."

After spending years grappling with self-doubt and difficult relationships — and smoking what he called "Snoop Dogg volumes of weed" from middle school until his 20s — he learned he had ADHD and dyslexia, two diagnoses that often overlap. He was 37.

It’s long been known that Black children are underdiagnosed for ADHD compared with white peers. A Penn State report published in Psychiatry Research in September studied the extent of the gap by following more than 10,000 elementary students nationwide from kindergarten to fifth grade through student assessments and parent and teacher surveys. The researchers estimated the odds that Black students got diagnosed with the neurological condition were 40% lower than for white students, with all else being equal — including controlling for economic status, student achievement, behavior, and executive functioning.

For young Black males, the odds of being diagnosed with ADHD were especially stark: almost 60% lower than for white boys in similar circumstances, even though research suggests the prevalence of the condition is likely the same.

The racial ADHD divide isn't merely a health concern. It's deepening inequity for Black children, and especially Black males, said the study's lead author, Paul Morgan, the former director of the Center for Educational Disparities Research at Penn State. He now leads the Institute for Social and Health Equity at the University of Albany.

ADHD has been diagnosed in nearly 1 in 10 children in the United States, according to a Centers for Disease Control and Prevention study published in 2022, with rates surging nearly 70% in the past two decades. It is often a lifetime condition that can be managed with treatments including therapy and medication. Untreated, children with ADHD face much greater health risks, including drug addiction, self-harm, suicidal behavior, accidents, and untimely death. By adulthood, many people with undiagnosed ADHD have spent years feeling isolated and hopeless, just as Wade did.

Even before Wade's diagnosis, he was helping similar college students in a career counseling role at North Carolina State University. Today, he's a licensed mental health and addiction counselor and doctoral student, but he said it's been hard to see his successes.

"To the rest of the world, this is a Black man with two master's degrees, and he’s a PhD candidate, and he has two licenses and certifications," he said. "But to me, I’m a brother who’s had a lot of bad luck with people and jobs I've gotten fired from. I’ve never been promoted, ever, in my professional life."

Wade's experiences of race and ADHD are intertwined. "ADHD is an accelerant to my Black experience," he said. "I can’t separate my experiences as a Black boy and Black man from my experiences of understanding my neurodivergent identity."

People who study and treat ADHD cite several reasons why young Black males fall under the radar, including teachers who are racially biased or have lower expectations of Black students and don't recognize an underlying disability, and Black parents who are distrustful of teachers and doctors, fearing they'll label and stigmatize their children.

"We’ve known for a long time that ADHD diagnoses are not made in a vacuum. They’re made in a geographic context, cultural context, racial context," said George DuPaul, a psychology professor at Lehigh University who studies nonmedication interventions for ADHD.

Studies have shown that ADHD underdiagnosis contributes to harsher school discipline and to the "school-to-prison pipeline." Black kids routinely face punishment, including criminal prosecution, for problem behavior and mental health conditions such as ADHD, while white kids are more likely to be diagnosed with behavioral conditions and receive medical treatment and support. There's a common saying: “Black kids get cops, white kids get docs.”

Courtney Zulauf-McCurdy, a researcher and clinician at the University of Washington School of Medicine, focuses on decreasing mental health disparities in early childhood. By preschool, she said, Black children with ADHD symptoms are more likely to be expelled and less likely to receive appropriate treatment than their white peers.

Her research has found that teachers' judgments of children are heavily influenced by their opinions of the kids' parents, and that often determines whether those children are evaluated for behavioral conditions and given appropriate support — or simply kicked out of class. She said the Penn State findings confirm what she's seen in clinics and heard from parents.

Zulauf-McCurdy also pointed to research that shows Black children are 2.4 times as likely as white kids to receive a diagnosis of conduct disorder compared with a diagnosis of ADHD. She said the racial bias and overdiagnosis of conditions such as oppositional defiant disorder, defined by symptoms of being uncooperative and hostile toward authority figures, result in more punitive consequences such as being isolated in separate classrooms.

To fix inequities in ADHD diagnosis, mental health experts see a need for increasing culturally sensitive screening and addressing Black families' concerns about potential bias and racism. Ensuring access to information about symptoms and treatments for ADHD may help address obstacles to care.

Looking back, Wade said, he is grateful he got diagnosed, even if it came late. But, he said, learning about his condition earlier would have given him more confidence navigating school, work, and life. "If I was able to get a diagnosis, I would have had a lot more support and love in my life," he said.

Behavioral tools and medication have made it easier for him to focus and to regulate his mood. The diagnosis has also helped him become more aware of how to manage his depression and anxiety.

"Now it's an understanding of how I exist, how my brain works," Wade said. "I don’t think that I’m just broken."

Still, Wade wonders what the ADHD label would have meant for him as a child — despite his family's privileges of money and education — before more awareness existed about the condition. Even now, he said, the remaining stigma around the diagnosis is probably worse for Black kids, who still get less benefit of the doubt than white children.

Today, Wade is helping Black and neurodivergent youth and adults identify ADHD and other conditions. It's part of his work, but it's also deeply personal.

"I remember how it felt to not be seen, to not be heard, and to have your needs dismissed," he said. "It feels good to see other people getting the help that they need and know that it helps Black people as a whole and generations of those families."