ADHD: Who Gets Diagnosed, Who Gets Overlooked, and What It Means for Kids’ Education

[MUSIC PLAYING] SARAH BALDWIN: From the Watson Institute at Brown University, this is Trending Globally. I'm Sarah Baldwin.

School is about more than just the subjects kids are supposed to learn. It's an essential part of their social and emotional growth. This is something we all know but sometimes take for granted, or at least we did before March 14, Twenty-Twenty.

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SPEAKER 1: Teenagers and children across the country are facing a mental health crisis.

SPEAKER 2: The CDC says between April and October, emergency departments saw a more than 30% spike in visits from children for mental health reasons.

SPEAKER 3: Doctors see the disruption in routine by not going to school or seeing friends. And the alienation of a life fully online can rewire the way we think.

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SARAH BALDWIN: The pandemic shined a harsh light on what exactly kids need to thrive. And one of the clearest takeaways from this period has been that no matter who you are, educational success, mental health, and our environments are inextricably linked. Nowhere is this connection more clear in all its importance and complexity than in conversations around ADHD or Attention Deficit Hyperactivity Disorder.

On this episode, we're looking at new findings about how this incredibly common and often misunderstood condition is diagnosed and treated. We'll also look at what it can teach us about the relationship between kids' mental health and their success in school, a topic which, after probably the hardest school year for many kids ever, is sorely in need of a rethink.

ADHD-- it's the most prevalent mental health diagnosis among children in America. 1 in 10 children in America is diagnosed with ADHD. What's really crazy is that that percentage has doubled in the past 25 years. Some say there's a crisis of overdiagnosis. Others say there's a crisis of unequal diagnosis, often falling along lines of race, gender, and class. So which is it?

JAYANTI OWENS: It's such a complicated question.

SARAH BALDWIN: That's Jayanti Owens.

JAYANTI OWENS: I'm an assistant professor of Sociology and Public Affairs at the Watson Institute at Brown University.

SARAH BALDWIN: Jayanti's made a career exploring how identities and social contexts affect a wide range of life outcomes, from how race affects high school suspension rates to how gender affects perceived performance in job interviews. And while she was studying things like school suspension and graduation rates, Jayanti noticed that one four-letter acronym kept coming up-- ADHD.

JAYANTI OWENS: I was really struck by the dramatic rise that we've seen and rates of ADHD diagnoses in recent decades. And given my interest in schools and academic pressure, this was sort of a diagnosis that I started to recognize was being commonly linked to these academic demands and pressures in a way that other behavioral disorders can be as well. But, really, the rates of rise in diagnoses of ADHD are especially striking.

SARAH BALDWIN: Like we said, these rates have doubled in the past 25 years. So Jayanti wanted to explore why and why it happened so unequally across the country. Is it the children's identity, their gender or race? Is it their income levels, the type of school they attend? Is it something in the water?

JAYANTI OWENS: So as a sociologist, this immediately led me to start thinking about, well, what features of social context matter?

SARAH BALDWIN: There was a problem, though, with answering this question. Most data on ADHD diagnosis has a sort of built-in selection bias. It only shows the rates of diagnosis among kids who were already brought in to be evaluated for it.

JAYANTI OWENS: But we know that there's really important demographic differences in the types of people who are able to get evaluated.

SARAH BALDWIN: Jayanti wanted to look at behaviors and diagnosis rates for all children. So Jayanti turned to a different kind of data set.

JAYANTI OWENS: The Early Childhood Longitudinal Study Kindergarten Cohort.

SARAH BALDWIN: This study was actually designed by the US Department of Education. It gathered information about the same group of students over long periods of time, from the students, their teachers, and their parents.

JAYANTI OWENS: They sample roughly 20,000 kids when they enter kindergarten.

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They resurvey them in the spring of kindergarten, the spring of first grade, the spring of third grade, fifth grade, and so forth.

SARAH BALDWIN: The surveys contain a ton of different information about the children's development, including if they were diagnosed with ADHD. This let Jayanti more accurately compare reported behaviors and actual diagnosis over a wide swath of society.

JAYANTI OWENS: It really gave me the ability to examine this question of, if you have two kids that are exactly the same, but one of them is in one type of environment with regards to academic pressure and the other is in a different type of environment, are there differences systematically in their likelihood of getting diagnosed?

SARAH BALDWIN: A funny thing happened as she started looking at the data from these studies. Jayanti realized that the kind of data sociologists gather for their analyses are similar to the data psychologists gather when making diagnoses, like ADHD. Both professions rely on data that's part qualitative, part quantitative, and often highly subjective. That last feature, subjective, is where things get tricky. But that's also where sociologists, like Jayanti, thinks it gets interesting.

JAYANTI OWENS: We tend to think, oh, doctors and clinicians-- there's a hard and fast rule for when a child is in a sort of area for needing a diagnosis for a certain mental health or behavioral disorder. And when I got into the literature, I realized that that's actually not true. And, in fact, within the diagnostic criteria that are used for things like ADHD diagnoses, it specifically says that the context plays a huge role in determining whether a child meets the diagnostic criteria in the first place.

SARAH BALDWIN: Thankfully, these massive longitudinal studies gave Jayanti the context that more clinical data often lacked. So after comparing tens of thousands of kids' behavior and experience in school and comparing that to rates of ADHD diagnosis among them, what did Jayanti find? Turns out one of the major drivers of ADHD diagnosis for children actually came from outside of school or rather from where school and home meet, what she calls parental intervention.

JAYANTI OWENS: If you have kids who have the exact same levels of inattention and hyperactivity and the exact same cognitive test scores when they're entering school, and you look at differences in their parents' level of intervention in school-- so this is things like attending conferences or reaching out to the teacher, being involved in parent teacher organizations, attending field trips or fundraisers, things like this-- that the kids of the parents that are more involved in school or more likely to intervene in school in these ways are more likely to get diagnosed.

SARAH BALDWIN: This finding has big implications, given what we know about what sort of parents intervene in school most.

JAYANTI OWENS: There's a lot of sociological research that basically shows that upper class and white parents are a lot more likely to be able to intervene in their children's schooling.

SARAH BALDWIN: By a sort of transitive property, Jayanti showed that privileged families are more likely to have children diagnosed with ADHD. But these findings brought up another question, one that we also need to understand. Why are privileged parents more likely to intervene in school? Part of it is because of the racialized nature of income inequality, where higher income, often white parents, have more time and flexibility to get involved in their children's school life. But as Jayanti explains, that's not the only reason.

JAYANTI OWENS: And there's also a whole host of sort of cultural factors too in terms of parents' beliefs about their role in their children's schooling. So even if the parents have the ability to intervene in school, they may not feel that that's the right thing to do because of the cultural understandings of deference towards authority figures like teachers and principals.

And so one of the things that I think that's most interesting in this area is research by people like Annette Lareau and Jessica Calarco. What their work shows is, really, that parents who are upper class and white tend to be more likely to feel entitled to intervene in school and to sort of advocate for their child in order to get certain benefits to their kids, so to get to know the teacher and then to be able to ask the teacher for things like extra help for the student or exceptions to deadlines for homework assignments or extra time on tests or any number of things that are not openly advertised and made readily available to all students but that are available if you have parents who are willing and able to intervene and sort of pull some strings.

SARAH BALDWIN: Thanks to the work of Jayanti and others, we're getting a clearer picture of how to maybe equalize the rates of ADHD diagnosis. And that's what we want, right?

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This is where things get really complicated. And that's because everyone who's diagnosed with ADHD doesn't experience it the same way. For some kids, it's a lifeline. For others, it's a stumbling block of its own. Reactions to an ADHD diagnosis are another issue Jayanti studied. And she's found that the very group that gets diagnosed most frequently for ADHD actually responds to that diagnosis the worst.

JAYANTI OWENS: Children from high social class backgrounds, middle and upper social class backgrounds, actually fare substantially worse following their diagnosis when it comes to things like their perceived self-competence and their teachers' ratings of their behaviors at school in part, because of the ways in which kids who are already privileged tend not to have previously been exposed to negative factors, negative stigma, like ADHD diagnoses.

SARAH BALDWIN: And the reaction is less negative for kids from disadvantaged backgrounds because, as she put it--

JAYANTI OWENS: If you're a student from a disadvantaged background, getting an ADHD diagnosis is probably not the first time that you've gotten a negative label in your life. You probably already learned to cope with that. Or even if you haven't, the sort of additional effect of this one extra stigma is relatively small relative to a privileged kid for whom this could be the very first time that they've been told that they're not perfect or that they're not excellent or wonderful in so many ways. And so the effect that can have psychologically and behaviorally on kids, I find, is actually a lot larger if they come from advantaged families.

SARAH BALDWIN: So does that mean more kids from less privileged backgrounds should be getting diagnosed? Not so fast. That's because the diagnoses of ADHD--

JAYANTI OWENS: It can also be used as a way to take children of color, socioeconomically disadvantaged children-- get them to sort of quiet down and be still in classrooms and to follow instructions in a way that's actually rather punitive. And, in fact, there's a whole lot of research suggesting that ADHD diagnoses and other types of behavioral disorder diagnoses can actually be used as a form of social control.

SARAH BALDWIN: Talking with Jayanti, it started to seem like when it comes to children's mental and behavioral health, answering one question almost always brings up two more. Every question-- why kids have certain behaviors, how those behaviors get noticed, how they get turned into diagnoses, and then how those diagnoses are understood and treated is kind of messy, which is something Jayanti says we can't shy away from.

JAYANTI OWENS: This messiness is hugely important.

SARAH BALDWIN: Take, for example, what often happens with children in privileged families in elite school systems, the groups with the most resources and access to expertise when it comes to supporting a kid's education.

JAYANTI OWENS: Parents, especially privileged parents, are spinning their wheels, doing all of these things to try to get their kid every advantage that they can get with the assumption that these interventions that they're making are positive for their child. So they're intervening in school. They're going to all the fundraisers. They're attending all the PTO meetings or PTA meetings. They're negotiating for their kid to get into the best class or the best teacher, et cetera.

The assumption is that all of these things are good, right? But, actually, you could imagine that all of these things are creating an environment for the child that places them under a tremendous amount of pressure. And there are some research suggesting that this pressure actually has the effect of making them feel that any deviations from perfection is incredibly problematic, that they're a failure if they haven't achieved at the highest possible level. And that can have a really negative effect on kids.

And so when an ADHD diagnosis is really apparently necessary, it's very clear that the child needs it, that's one thing. And that has beneficial outcomes or can have beneficial outcomes for kids. But for the kids who are in this sort of gray area where it's not clear whether the diagnosis is really a clear-cut need for the child or if it's largely the result of the social context in the academic pressure placed on the child, then, actually, the diagnosis may not be beneficial. And so it's, I think, really important for parents and educators and clinicians to sort of really weigh those pros and cons when it comes to making a diagnosis in a particular case.

SARAH BALDWIN: Especially as diagnoses continue to rise, and that gray area is seemingly getting larger and larger. It was at this point in the conversation that we turned back to the pandemic and the seeming lack of clear answers about how to help children through it.

Take what we've been looking at in this episode as an example. By many measures, diagnoses of ADHD increased significantly during the pandemic. And while on one hand it seems kind of obvious, we don't yet have clear answers as to why.

Did kids have ADHD before the pandemic and were just undiagnosed? Or did more kids develop the disorder because they were stuck at home? Jayanti hasn't dug into the data on ADHD during the pandemic. But there's one thing that her work has shown.

JAYANTI OWENS: It's not a straightforward diagnosis. Whether a child is getting underdiagnosed or overdiagnosed, it really depends on their context and their actual behaviors. And we don't always know what those behaviors are or what that context actually is demanding of the child.

SARAH BALDWIN: But we do know those contexts changed massively this past year.

JAYANTI OWENS: For the first time in a long time, for many parents, they were forced to be involved in the day-to-day functioning of their children while they were, quote, "at school," when in reality, they were at home. And so this may have had the effect of making parents or many more parents aware of exactly what their children's behaviors are in the classroom even though it was a virtual classroom.

And so it wouldn't surprise me if that would create an awareness on the part of parents about problems that their child may have been having for a long time but that they were just not previously attuned to because they weren't attending school with their child. And, additionally, I think just the stress caused by the pandemic could also have led to a true uptick in the types of behaviors that are diagnosed with ADHD.

SARAH BALDWIN: On Trending Globally, we like to end episodes with solutions or policy proposals that could maybe fix the issues we bring up. But that's not going to happen today. As Jayanti made clear in our conversation, diagnosing these issues in children is so complicated, so context-specific that the solutions aren't easy to list out.

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When it comes to who gets what labels and why and what interventions help who and why, we're still diagnosing the problem. But one thing is clear, we need to learn a lot more about how kids' mental health intersects with their social context and how it all relates back to their success in school. And this is where we might see a tiny silver lining from the pandemic.

JAYANTI OWENS: I think with the magnitude of learning gaps that we've seen, learning loss as a result of the pandemic, I think people are just a lot more aware about the challenges of learning when you're under mental health duress.

SARAH BALDWIN: Even though these issues have been around all along--

JAYANTI OWENS: This is not a new thing. There are many kids for whom going to school with emotional duress and psychological duress is not new.

SARAH BALDWIN: --these issues are getting discussed at a level they never have been before.

JAYANTI OWENS: The cross-section of American children who have experienced this duress in learning has skyrocketed over the last year.

SARAH BALDWIN: The pandemic hasn't just raised awareness of these issues. It's also maybe created whole new opportunities to learn about them. Has the pandemic sort of served as a natural experiment? Or is that an overstatement?

JAYANTI OWENS: Absolutely, yeah. So there's a whole branch of social science that studies natural disasters. And the reason for that is, in part, because natural disasters kind of strike at random. And so much like that, the pandemic, I think, it was kind of an equal opportunity offender in certain ways.

I mean, we clearly know that disadvantaged communities and communities of color were hit hardest by the pandemic. And that is not random. That is very much not random. But for privileged parents, for high social class parents, I think the effects of the pandemic were felt much more widely than if it hadn't been for the pandemic.

SARAH BALDWIN: Hopefully, as a society, we'll keep this conversation about mental health schooling and inequality at the top of our mind after seeing the confusion and pain this past year caused. And maybe a once-in-a-century pandemic will allow more researchers, like Jayanti, to look at the data and help guide us towards some answers.

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This episode was produced by Dan Richards and Kate Dario. Our theme music was composed by Henry Bloomfield. I'm Sarah Baldwin.

You can listen to all our episodes any time, anywhere by subscribing to Trending Globally wherever you listen to podcasts. We'll be back soon with another episode of Trending Globally. Thanks for listening.