ADHD in Children: Who Gets Overlooked and How the Pandemic Has Made Learning Harder

By Denise-Marie Ordway

An estimated 9.6% of U.S. children were diagnosed with attention-deficit/hyperactivity disorder, commonly known as ADHD, from 2015 to 2018, according to a 2020 report from the Centers for Disease Control and Prevention.

However, diagnosis rates among kids aged 3 to 17 years vary considerably by state, from 5.1% in Nevada to 16.6% in Kentucky, according to state-by-state data the CDC collected in 2011, the most recently available. While diagnoses have risen since 1997, the neurodevelopmental disorder appears to be most prevalent in rural areas. On average, 11.4 % of rural children have been diagnosed with ADHD, compared with 9.2% of children in urban areas, the CDC report shows.

Kids with ADHD have difficulty focusing, taking turns and controlling their behavior – chronic symptoms that interfere with learning and making friends and make it tough for teachers to keep a classroom of students on task.

“For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning, and cause the person to fall behind typical development for their age,” according to the National Institute of Mental Health. “ADHD symptoms can appear as early as between the ages of 3 and 6 and can continue through adolescence and adulthood. Symptoms of ADHD can be mistaken for emotional or disciplinary problems or missed entirely in children who primarily have symptoms of inattention, leading to a delay in diagnosis.”

Amid the COVID-19 pandemic, the symptoms of ADHD pose an even greater challenge for the children who have it and the schools that serve them. Educators nationwide are struggling to help all kids catch up in their studies following school closures in 2020 and 2021, and help all students deal with the anxiety, depression and other mental health issues brought on or made worse by the pandemic.

Journalists reporting on the issue can look to academic research to help them ground and contextualize their coverage. While some findings published in recent months cannot be generalized or applied to anyone outside the sample of people studied, they offer important insights.

Studies published in 2022 provide evidence that:

• The pandemic has exacerbated ADHD symptoms for many students.
• Teachers, who play a key role in the diagnostic process, are less likely to spot ADHD symptoms in girls, especially the oldest girls in their classes. Teachers sometimes mistake the behavior of their youngest male students for symptoms of ADHD.
• Racial and ethnic minorities and children whose families have a lower socioeconomic status are less likely to be diagnosed with and receive medication to treat ADHD than are white children and kids whose families have a higher socioeconomic status.
• Overdiagnosis is most prevalent among white students and kids from higher socioeconomic backgrounds.
• Teenagers with ADHD are less likely to receive and have confidence in COVID-19 vaccines.
• High school students who have experienced trauma such as abuse, neglect and the loss of a loved one are more likely to have ADHD. And high school students who report having ADHD are suspended from school more often than students who do not have it.

ADHD researcher Paul L. Morgan, a professor of education and demography at Penn State, says that while ADHD is not a new issue in education journalism, there are plenty of angles worthy of news outlets’ attention. For example, recent work suggests Black girls in the U.S. are often under-diagnosed for ADHD.

Journalist Claire Sibonney has covered the issue for Kaiser Health News.

“Already subject to unique discrimination at the intersection of gender and race, Black girls with ADHD often remain undiagnosed because their symptoms are mischaracterized,” Sibonney reports. “Signs of inattentiveness or impulsivity, two main features of the disorder, could be mistaken for laziness or defiance.”

Morgan, who’s also director of the Penn State Center for Educational Disparities Research, says he would like to see journalists report on ADHD among girls who are racial and ethnic minorities as well as students whose primary language is not English.

“I would like to see more coverage of the barriers to diagnosis in non-White and non-English-speaking communities,” he wrote via email while traveling for work.

Morgan pointed out that scholars are trying to understand why ADHD diagnoses are on the rise. Studies suggest the increase might be driven in part by overdiagnosis. Teachers generally contact parents or initiate a diagnostic referral when they suspect a child has ADHD.

“There has not yet been much empirical study of the groups of children who are likely being over-diagnosed and treated for ADHD, despite repeated findings suggesting that increasing prevalence may in part be explained by over-diagnosis,” Morgan wrote via email. “To what extent parents may be using ADHD diagnosis and treatment as a way to increase their children’s academic achievement, particularly in privileged communities, is unclear.”

Another issue needing investigation: whether and how social media might be influencing diagnoses and treatment. If social media is helping disseminate information about ADHD, that also might prompt more children and their families to seek help from medical professionals.

To help journalists investigate these and other angles, we’ve summarized a sampling of the papers published in 2022 that look at ADHD in children. We will periodically update this list as new research becomes available.

COVID-19 and ADHD

Systematic Review: Investigating the Impact of COVID-19 on Mental Health Outcomes of Individuals With ADHD
Julie T. Behrmann, Julie Blaabjerg, Josefine Jordansen and Kristine M. Jensen de López. Journal of Attention Disorders, May 2022.

The coronavirus pandemic has affected the mental health of individuals diagnosed with ADHD in various ways, including exacerbating ADHD symptoms and heightening feelings of loneliness, anxiety and sadness, according to a systematic review of studies of the issue.

Researchers examined 12 studies conducted in nine countries involving a combined 3,028 people ranging in age from 4 to 27 years.

Most studies “identified negative behavioral outcomes with respect to symptoms of ADHD such as increased activity levels, inattention, impulsivity, restlessness, and disruptive behavior,” the authors write. Five studies found individuals with ADHD experienced poorer sleep quality and spent more time watching TV, using social media and playing video games.

“The impact of the pandemic was generally negative,” the authors write. “Increased challenges within the domain of social competences were reported in terms of isolation and relationships with parents. These aspects, along with the negative impact of lack of peer exposure may be particularly acute for tweens and adolescents, while having less impact on younger children, young adults, and adults with ADHD.”

The findings indicate some people with ADHD experienced positive changes, however – improved mood and academic performance, for example. The authors explain that differences in the experiences of people with ADHD “may be attributable to the fact that individuals with ADHD constitute a heterogeneous group and consequently display different symptoms during the COVID-19 pandemic depending on, for example, emotion regulation, IQ and the severity of existing ADHD symptoms.”

COVID-19 Resulted in Lower Grades for Male High School Students and Students With ADHD
Rosanna Breaux; et al. Journal of Attention Disorders, May 2022.

This small study looks at how the COVID-19 pandemic affected the grade-point averages of different groups of students during the 2020-21 academic year. The key takeaway: GPAs fell across several student groups but students diagnosed with ADHD saw a larger reduction.

The authors drew their findings from a sample of 238 students at two high schools, one in the southeastern U.S. and the other in the Midwest. About half the students were diagnosed with ADHD prior to the pandemic, 55% were male and 82% were white.

The average GPA for students with ADHD dropped from a 3.51 in Spring 2020 to a 3.28 in Fall 2020. Boys, as a whole, saw their GPAs slide from a 3.63, on average, to a 3.45. GPAs for Latino students who aren’t Black dipped to a 3.56, down from a 3.69.

Adolescents With ADHD Are At Increased Risk for COVID-19 Vaccine Hesitancy
Melissa R. Dvorsky, Rosanna Breaux, Joshua M. Langberg and Stephen P. Becker. Journal of Psychiatric Research, June 2022.

Teenagers with ADHD expressed less confidence in the safety of COVID-19 vaccines and less willingness to receive them than did teens without ADHD, this study finds. In fact, kids with ADHD were more than twice as likely to be vaccine hesitant.

Researchers examined the results of four online surveys that a sample of 196 high school students completed from March to May 2021. The students, half of whom had ADHD, attended two high schools in the Southeast and Midwest.

When kids were asked, “If a vaccine that could prevent COVID-19 were made available to you, would you accept it for yourself?” 9% said “maybe” and 9% answered “no.” But 24% of students with ADHD said “maybe” and 15% said “no.”

The teenagers also were asked to rate how closely they agreed or disagreed with the statement, “I am completely confident COVID-19 vaccines are safe.” While 39% of all the students reported they “strongly agree,” 22% of kids with ADHD did.

Researchers indicate that difficulty regulating attention and behavior could influence a teen’s attitude about COVID-19 vaccines.

“Vaccine uptake, willingness, and confidence is especially low among adolescents with ADHD, perhaps in part due to core symptoms of ADHD and associated impairments likely impacting planning, motivation, and execution of vaccination, risk appraisals and perceived susceptibility to COVID-19,” they write.

Diagnosing ADHD

Sociodemographic Disparities in Attention-Deficit/Hyperactivity Disorder Overdiagnosis and Overtreatment During Elementary School
Paul L. Morgan, Adrienne D. Woods and Yangyang Wang. Journal of Learning Disabilities, 2022.

Morgan is the lead author on this study, which suggests U.S. schoolchildren are overdiagnosed with ADHD and that white kids and kids from higher socioeconomic backgrounds are most likely to be overdiagnosed.

The authors studied a sample of 1,070 children who had been diagnosed with ADHD at some point between the first and fifth grades. The sample is a subset of students who participated in the Early Childhood Longitudinal Study: Kindergarten Class of 2010–2011, which followed a nationally representative group of children from the fall semester of kindergarten through the spring semester of fifth grade.

Each year of the study, teachers and parents rated kids’ behavioral functioning and field staff from the National Center for Education Statistics assessed their executive functioning. Children also took tests to demonstrate their academic achievement.

Researchers discovered that children who rated “above average” in terms of their behavioral, academic or executive functioning – meaning they probably did not have ADHD — were more likely to be diagnosed with and treated for ADHD if they were white.

For example, 27.3% of white children diagnosed with ADHD had demonstrated above average academic achievement prior to their diagnosis. About 19% of racial and ethnic minorities did.

Likewise, 30.4% of children who were diagnosed with ADHD after displaying above average levels of academic achievement were from high socioeconomic backgrounds, and 20.1% were low socioeconomic backgrounds.

The authors offer several possible explanations for the differences. For one, they suggest wealthier families might be seeking ADHD diagnoses for their children to gain access to ADHD medication, designed to improve kids’ ability to focus.

“Our results are consistent with some White families being more likely to seek out ADHD diagnoses and treatments for their children even when their children display no or only mild symptoms or impairments, possibly so as to increase the children’s academic achievement,” the authors write.

Meanwhile, many parents who are not white might be resisting ADHD diagnoses. They “have reported skepticism about the accuracy of ADHD diagnosis and treatment by providers and instead are more likely to view diagnosis and treatment as an attempt to exert racialized social control or because school environments are unresponsive to the needs of non-White children,” the authors write.

ADHD Misdiagnosis: Causes and Mitigators
Jill Furzer, Elizabeth Dhuey and Audrey Laporte. Health Economics, June 2022.

Kindergarten teachers often mistake boys’ behavior for symptoms of ADHD, especially the behavior of their youngest male students, finds this 15-year study of Canadian schoolchildren. Kindergarten teachers also tended to miss ADHD symptoms in girls, especially the oldest girls in the class.

“For the youngest students, teachers misattribute their relative immaturity as ADHD, while overlooking the oldest students if their behavior is comparatively controlled,” write the authors, who examined data for a sample of 7,510 kindergarten students who participated in Canada’s National Longitudinal Survey of Child and Youth, launched in 1994 with follow-up surveys every two years until 2008.

The researchers note that teachers with special education training don’t make such errors. They also note that red shirting – when parents postpone kindergarten entry for a year, often to give their children more time to mature – appears to “limit over-assessment of the youngest males to some degree.” But the practice, more common among higher-income families, “provides a pathway by which socioeconomic inequality may generate inequalities in health and education outcomes.”

ADHD, trauma and student suspension rates

Why Are We Really Suspending this Student? The Relationship Between Adverse Childhood Experiences, ADHD, and High School Suspension Rates
Kelly Wynne Lettieri and Travis Lewis. Journal of Trauma Studies in Education, May 2022.

This small study of students at a high school in the southeastern U.S. finds that kids who experienced trauma earlier in their childhood were more likely to have ADHD. It also finds that students who reported having ADHD were suspended from school more often.

For the study, 750 students answered 10 questions about their childhoods to gauge whether they had experienced trauma such as abuse, neglect or the loss of a loved one. Their responses determined their ACE, or Adverse Childhood Experiences, score. Students also completed a demographic questionnaire that included questions about whether they had been diagnosed with ADHD and took medication for it.

Researchers collected student disciplinary data and used that information to determine whether having an ADHD diagnosis is linked to high suspension rates and high ACE scores. ACE scores are higher for kids who reported experienced multiple traumatic events.

The researchers write that their findings “are significant because they provide evidence of a link between trauma and negative student behaviors in schools.” They also stress that pediatricians should conduct trauma screenings when evaluating children exhibiting symptoms of ADHD.

“When presented with symptoms that appear similar to that of ADHD, if there is no trauma assessment such as the ACE questionnaire administered, the result may be a diagnosis of and prescription for medication for ADHD,” they write. “The problem with this outcome is that, while the medication may help to treat some symptoms such as difficulty paying attention, hyperactivity, and being easily distracted, it is not treating the root of the problem, which is the trauma that occurred during the individual’s childhood or may still be occurring when the doctor treats them for ADHD.”

The authors recommend teachers, administrators and other school personnel receive trauma-related training to reduce the amount of class time students lose when they get suspended for what might be trauma-related behavior.

The Journalist’s Resource is part of the Mental Health Parity Collaborative, a group of news organizations that are covering challenges and solutions to accessing mental health care in the U.S. The collaborators on this project include The Carter Center, The Center for Public Integrity, and newsrooms in Arizona, California, Georgia, Illinois, Pennsylvania, and Texas.

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This article first appeared on The Journalist’s Resource and is republished here under a Creative Commons license.

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