Attention Magazine April 2023

The national rate of preschool ADHD in the United States increased from 1.0% in 2007 to 2.4% in 2016. Although preschoolers with ADHD often do not receive a diagnosis until later, early and effective interventions can blunt the typical developmental progression seen with ADHD (lower academic achievement, for example) and mitigate the need for further treatment and a formal diagnosis.

For any child under the age of six displaying ADHD symptoms, the American Academy of Pediatrics recommends behavioral interventions, before medication and regardless of a diagnosis. Behavioral interventions include behavioral parent training and classroom behavior management. These interventions focus on training the parent or teacher to support or manage the child’s behavior. Too often, preschool children do not get the help that they need due to adults’ negative perceptions of the child’s behavior. Research tells us that this is particularly true for Black preschoolers.

Two children, two different approaches

Let’s look at two examples of mothers seeking help for their preschool children. The mother of Eric, a four-year-old boy, described how his teacher recommended she seek behavioral support because he would hit his peers when they took his toy. On the other hand, the mother of Matt, a five-year-old boy, sought help when her son was kicked out of preschool for hitting his peers.

Preschool is a time of rapid development when young children are learning social, emotional, and behavioral skills necessary for success. As children are learning these skills, it is common for them to have difficulty sitting still, controlling their impulses, and paying attention. So, how do we know if Eric’s or Matt’s behavior would benefit from a behavioral intervention? Behavioral interventions can support the development of all children developing social-emotional skills, not just those with ADHD. However, as seen in the comparison of how Eric and Matt’s teachers responded to their behavior, adults can have drastically different approaches to the same behavior. Unfortunately, perceptions of child behavior are often subjective decisions.

Let’s revisit the case of Eric and Matt and explore potential reasons why their teachers’ approaches to their behaviors were so drastically different. Eric’s mother described how his teacher reached out to her early on to discuss her concerns about his behavior. Following an honest conversation, they decided that behavioral interventions may benefit Eric at home and school. Matt’s mother had a very different experience. She described feeling caught off-guard about his behavior and expulsion. She was seeking support after the fact because Matt’s school didn’t offer any alternatives. Eric’s teacher believed he could benefit from behavioral support, whereas Matt’s teacher viewed him as dangerous and disruptive. Now let me mention that Eric identified as White and Matt as Black.

The subjective nature of evaluating child behavior in preschool can open the door to both explicit and implicit biases about race. Racism within our country has created a narrative that Black families are broken; Black fathers are absent; Black mothers are loud and uneducated; and Black children are bad. Cultural racism has a trickle-down effect on how teachers respond to child behavior in preschool, with Black children more often punished for their behavior. It also affects teachers’ perceptions of families and their process of joining with families in behavioral interventions.

Disparities, suspensions, and expulsions

Despite the potential benefits of behavioral interventions, research tells us that Black children are less likely to be identified as needing support and less likely to receive appropriate treatment compared to White children. Preschool teachers may be more likely to pathologize Black children’s behavior, placing the cause of the behavior on the child or their family, rather than keeping the focus on the behavior itself. Once the cause of the behavior is on the child or family, teachers may be less likely to recommend a behavioral intervention. The result? Some preschool children with symptoms of ADHD and externalizing disorders are placed on the “cradle-to-prison pipeline” or the disturbing national trend wherein children are funneled out of their preschool center and into the criminal justice system.

Preschoolers who demonstrate ADHD symptoms are at a higher risk of being suspended or expelled from preschool or daycare compared to their peers. We also know that expulsion disproportionally affects Black children, with 47% of children who are expelled from preschool being Black, although Black children only make up 19% of preschool enrollment (US Department of Education, 2016). Therefore, young Black children who demonstrate ADHD symptoms are at an even higher risk of expulsion. Children who are expelled are subsequently more likely to have academic failure and to be in contact with the juvenile justice system. When a child is expelled, they are not only denied access to a preschool setting designed to help them work through behavioral challenges, but they are also denied the appropriate behavioral interventions that can minimize ADHD symptom escalation.

Disparities in how adults perceive and respond to the behavior of Black children don’t just exist in preschool. Black children are 17% less likely to be diagnosed with ADHD but are over 2.4 times more likely to receive a diagnosis of conduct disorder. Black children are overdiagnosed with neurodevelopmental disorders and disabilities and are overrepresented in special education. Even if a family of a Black child can access the appropriate behavioral interventions for ADHD, well-established evidence-based programs are less effective (lower rates of satisfaction, and appropriate treatment selection).

Disparities in how ADHD symptoms are perceived are not a result of the child. Rather, disparities are embedded within the larger context of a system that is sometimes unaware of its own injustices. Changes in schools and in the mental health field should focus on what individuals can do to support young Black children with ADHD and their families. The following section explores a few areas and urges the field to continue the discussion, as the suggestions are not exhaustive.

Recommendations for all individuals

• Acknowledge that racism is prevalent in preschool and our mental health field, influencing every aspect of ADHD prevention, treatment, and research.
• Educate yourself (on an ongoing basis) on how racism has affected Black children with ADHD and their families through intentionally selected materials.
• Be open to change. Acknowledge your inherent biases and how they appear in interactions with Black children and their families.
• Take ownership of your mistakes. Formalize processes that include seeking feedback to reflect on your own biases and challenge your assumptions.
• Sit in discomfort and create space for difficult conversations.

Recommendations for teachers

• Don’t pathologize child behavior. Try to understand its purpose, see it as a normal part of development, and seek support when needed. Identify culturally responsive practices for responding to child behavior.
• Educate yourself on behavioral interventions for ADHD and related disorders.
• Include the child’s parents when a concern arises. Reach out to parents right away. When speaking with parents, model a stance of respectful openness while leaving your assumptions at the door. Even if you disagree, strive to set a tone that maximizes the possibilities for considering different viewpoints. Seek to join with parents to implement proper behavioral interventions.

Recommendations for researchers

• Acknowledge that most research on ADHD comes from a White middle-to-upper-class sample of males. Understand how this has unintentionally widened disparities and caused harm to Black children and their families.
• Work towards adapting our current evidence-based practices for ADHD to fit the needs of Black children and their families in a culturally responsive way.
• Include scholars of color on your research team.
• If you are interested in researching issues of race and disparities, be intentional. Seek out methods that allow you to learn from Black children and their families (e.g., advisory boards, qualitative research).

Courtney Zulauf-McCurdy, PhD, is a clinical psychologist and acting assistant professor with a dual appointment in psychiatry and behavioral sciences and general pediatrics at the University of Washington. She is a member of the Program to Enhance Attention, Regulation, and Learning (PEARL) Clinic and the Center for Child Health Behavior and Development (CHBD) at Seattle Children’s Research Institute. The central focus of her research and clinical work is on reducing ADHD disparities starting in preschool, by improving parent and teacher engagement in behavioral interventions. Dr. Zulauf-McCurdy acknowledges that her positionality as a White female with an advanced degree in clinical psychology influences her work with young children and their families placed at risk for ADHD.