Impact of Maternal and Child Race on Maternal Ratings of ADHD Symptoms in Black and White Boys

Abstract

Objective: Examine the influence of maternal and child race on ADHD symptom ratings. Method: Participants were Black (n = 63) and White (n = 68) mothers randomly assigned to view a 13-min videotape of either a Black or White boy displaying similar levels of ADHD-related behaviors during free play and meal situations. Mothers then completed an ADHD rating scale. Results: With maternal age and socioeconomic status (SES) as covariates, Black mothers provided significantly higher ratings of inattentive and hyperactive–impulsive symptoms than did White mothers regardless of child race. The effect of child race was not statistically significant. Conclusions: Maternal race appears to be more important than child race in accounting for differences in ADHD symptom ratings between Black and White boys. It is critical to understand variables related to these differences and develop assessment measures that lead to equivalent, accurate diagnostic decisions across racial subgroups.

Keywords

ADHD assessment ethnic minorities race rating scales

ADHD is a chronic neurodevelopmental disorder that affects 3% to 10% of the child population and is associated with significant academic (e.g., poor grades, higher than average risk for school dropout) and/or social (e.g., peer rejection) impairment (American Psychiatric Association [APA], 2013). As such, it is critical to identify children with ADHD in a reliable and valid fashion so that treatment resources can be allocated to those in greatest need.

Current best practice in diagnosis of ADHD involves multiple assessment methods and respondents to document symptoms and impairment across home and school settings (Pelham, Fabiano, & Massetti, 2005). Chief among assessment methods are behavior rating scales wherein parents and teachers report the frequency and severity of symptomatic behaviors associated with ADHD and other psychiatric disorders. There are several important advantages of rating scales relative to other assessment methods including time-efficiency, information obtained from respondents who observe child behavior in natural settings on a regular basis, documentation of behavioral symptoms based on diagnostic criteria, evaluation of symptom frequency and severity based on age- and gender-based normative data, established reliability and validity, and use for a variety of purposes including screening, diagnosis, and evaluation of treatment response (Barkley, 2015). Furthermore, parent and teacher ratings provide unique data, above and beyond information from diagnostic interviews, regarding child behavior across settings and, as such, are the most important components of a diagnostic evaluation of ADHD (Vaughn & Hoza, 2013).

Behavior rating scales also have several limitations (e.g., subject to setting variance as a function of situational specificity of behavior, lack of specificity, and precision in response options; Egger & Angold, 2006); chief among these is that despite appearances of objectivity, ratings involve subjective views of respondents and may be biased by various factors including cultural context (Reid, 1995; Weisz & McCarty, 1999). One powerful cultural context is the racial background of the respondent and the child being assessed.

Several studies have shown that Black children, particularly males, receive significantly higher ratings of ADHD symptoms from adults than do White children (e.g., Arnold et al., 2003; Epstein et al., 2005). In fact, the pooled Cohen’s d effect size from these studies was 0.45 indicating that ADHD behavior ratings were, on average, nearly one-half standard deviation higher for Black than for White children (Miller, Nigg, & Miller, 2009). It should be noted that participants in these samples were, for the most part, from the general population and not selected for elevated symptoms or clinically referred. All but one of these studies examined teacher ratings; however, the one investigation assessing racial differences in parent ratings also found significantly higher symptom ratings for Black versus White children associated with a slightly smaller effect size than for racial differences in teacher ratings (d = 0.31; DuPaul, Anastopoulos, et al., 1998). Thus, racial group differences in child symptom ratings are evident even when informants are of the same race as the child. Although the effects of socioeconomic status (SES) were controlled in the DuPaul et al. study, the degree to which racial group differences are accounted for by child race, informant (i.e., parent, teacher) race, SES, or actual behavioral differences in exhibition of ADHD symptoms remains unclear.

In contrast to findings of elevations in ADHD symptom ratings for Black children, studies have consistently found significantly lower diagnostic and treatment rates for ADHD in the Black population (Miller et al., 2009). For example, using nationally representative data from the Early Childhood Longitudinal Study–Kindergarten, Morgan, Staff, Hillemeier, Farkas, and Maczuga (2013) found that Black children were 69% less likely than White children to receive an ADHD diagnosis and were significantly less likely to be taking prescription medication for the disorder. The contradictory findings of elevated symptom ratings on one hand and lower diagnosis and treatment on the other could be explained by decreased access to and use of services by Black families (Miller et al., 2009). In fact, one of the factors decreasing risk of an ADHD diagnosis in the Morgan et al. study was lack of health insurance (i.e., diminished access to clinical services). Given the apparent disparities in diagnosis and treatment of ADHD, it is critical to more systematically examine racial differences in assessment outcomes.

At least two factors (other than actual differences in ADHD prevalence) could account for possible racial differences in ADHD symptom ratings. First, SES and race are linked given the significantly higher risk for low SES status among Black versus White families (Office of the Assistant Secretary for Planning and Evaluation, 2012) (Department of Health and Human Services, 2012). Thus, it is important to account for SES when examining racial differences in psychiatric symptoms as health status ratings provided by Black and White adults may be equivalent when SES is controlled (e.g., Lo, Howell, & Cheng, 2013). It is also possible that racial differences in ADHD symptom ratings could be moderated by the interaction between adult and child race. That is, symptom ratings of children may differ as a function of the race of the adult completing the ratings; Black and White adults may rate Black and White children differently based on cultural biases. Although possible adult by child race interaction effects have not been investigated for parent ADHD symptom ratings, some studies have found that teacher ratings of classroom behavior vary as a function of the match between teacher and student race (e.g., Downey & Pribesh, 2004).

Based on the scant available studies, it is unclear whether differences in ADHD symptoms are associated with parent race, child race, or their combination. One way to assess possible cultural differences in behavior ratings is to have participants from different cultural backgrounds complete symptom ratings after viewing videotape vignettes of children displaying symptomatic behavior. In this manner, investigators can control the informant race, child race, and the actual frequency and severity of behavioral symptoms being rated. In an early study using this methodology, Stevens (1981) had parents, school psychologists, and teachers (93% of whom were White) view brief (3-min) silent films of boys of different ethnic backgrounds (Black, White, Mexican American) displaying identical levels of inattentive, hyperactive–impulsive behavior in a small classroom setting. Respondents completed a nine-item rating scale of hyperkinetic behavior following the viewing of each film. Parents provided significantly higher ratings of hyperkinetic behavior for the Black child than for the other two children. Because virtually all parents were White, no analyses regarding the effects of parent race were reported.

Mann et al. (1992) investigated possible differences in ratings of hyperactive-disruptive behaviors among mental health professionals from China, Indonesia, Japan, and the United States. Participants viewed brief videotapes of four different children (two from Tokyo, two from Honolulu) engaged in individual and group activities. Ratings of hyperactive-disruptive behaviors were completed at the conclusion of each videotaped vignette. In all four cases, mental health professionals from China and Indonesia provided significantly higher ratings than professionals from Japan and the United States. There was also a significant main effect for videotape (i.e., child being rated); however, Mann and colleagues do not discuss child behavior differences in any detail because their main interest was differences among informants.

The degree to which child ethnicity affected ADHD symptom ratings between Hispanic and White, non-Hispanic teachers was investigated by de Ramirez and Shapiro (2005). Teachers were randomly assigned to view a videotape of a White, non-Hispanic or Hispanic child engaging in ADHD behaviors in the context of group and individual classroom activities. Videotapes were edited such that the two children displayed relatively equivalent levels of inattention, impulsivity, and motor activity (i.e., child ADHD symptoms were controlled). Ratings of ADHD symptoms and teacher acculturation level were then completed. A significant main effect for teacher ethnicity was found wherein Hispanic teachers provided significantly higher ratings of hyperactive–impulsive, but not inattentive, behavior. There was no main effect for child ethnicity or an interaction between teacher and child ethnicity. Furthermore, when acculturation scores were included as a covariate, teacher ratings were no longer different between ethnic groups. Thus, the ethnicity of the rater impacted ADHD symptom ratings; however, group differences were largely accounted for by informant acculturation.

The results of these videotape vignette studies are intriguing as they suggest that informant and child cultural background may impact ratings of child ADHD symptoms to a significant degree. Unfortunately, no prior studies have utilized this methodology to examine the impact of informant race, child race, and their interaction on parent ratings of ADHD symptoms. The use of this methodology may help to ascertain what factors (e.g., SES, actual child behavior differences) account for findings of elevated symptom ratings for Black children. This research direction is particularly important given the dearth of studies examining the impact of race on parent ADHD symptom ratings.

The purpose of the current study was to examine influence of parent and child race on ADHD symptom ratings in an analog situation where parents of both races were randomly assigned to observe video of either a Black or White child exhibiting similar levels of symptomatic behaviors. Given the established association between race and SES, we included SES as a covariate to statistically control the effect of this variable on ADHD symptom ratings. The research question was whether ADHD symptom ratings differ as a function of maternal race, child race, and the interaction of these two factors. Based on prior findings of elevated ADHD symptom ratings for Black children (Miller et al., 2009), it was hypothesized that ratings from both Black and White mothers would be significantly higher for the Black than for the White child (i.e., significant main effect for child race). Given that prior studies have not examined main effect of parent race or the interaction between parent and child race, no specific predictions were made regarding these effects.

Method

Participants

Participants (N = 131) were volunteers recruited from community organizations (e.g., faith-based institutions, Parent-Teacher Associations [PTAs], community hockey league) in suburban and urban locations in the Northeast (n = 14), Mid-Atlantic (n = 64), Southeastern (n = 40), and Midwest (n = 13) regions of the United States. Participants were the legal guardian, primary caregiver (e.g., grandparent), or biological parent of a child enrolled in Grades K-12. Participants were included if their native language was English and they self-identified as either Black (n = 63) or White (n = 68). Only female respondents were included to minimize gender confounds and because maternal ratings are most commonly used in clinical and research settings. Respondents in both racial groups were primarily from middle-class SES backgrounds and in their 30s and 40s (see Table 1). Although Black and White respondents did not differ with respect to SES (p = .09), there was a significant difference in age (p < .01) with Black parents younger than White parents.

Table 1.

Descriptive Statistics for Participant Characteristics and Ratings.

	Black parent		Black parent		White parent		White parent
	Black child		White child		Black child		White child
Measure	M	SD	M	SD	M	SD	M	SD
Maternal age	39.35	6.31	39.91	6.57	43.97	6.99	43.64	5.72
Hollingshead index	56.77	8.78	58.28	8.43	59.28	6.26	60.14	5.62
Inattention raw score	21.84	4.51	18.59	5.07	16.78	6.73	16.72	6.11
Hyperactivity–impulsivity raw score	20.52	4.59	18.88	3.26	16.12	6.58	17.58	3.77

Design

Black and White parents were randomly assigned to one of two conditions. One condition involved parents watching a videotape of a Black child displaying behaviors representing clinically significant ADHD. The other condition involved watching a videotape of a White child displaying the same type/level of ADHD behavior. There were four possible combinations: Black mother watching a Black boy (n = 31), White mother watching a Black boy (n = 32), Black mother watching a White boy (n = 32), and White mother watching a White boy (n = 36).

Instrumentation

The ADHD-IV Rating Scale Home Version (ARS-IV Home Version; DuPaul, Power, Anastopoulos, & Reid, 1998) was used to obtain maternal ratings of child ADHD symptoms. This is an 18-item scale that is directly adapted from the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000). Respondents report the frequency of each behavior on a 4-point Likert-type scale (0 = never/rarely to 3 = very often). For the purposes of this study, parents were asked to rate behaviors based on their observation of child behavior in the videotape. The psychometric properties of the ARS-IV are well established (DuPaul, Power, et al., 1998). Total scores on the Inattention (IA) and Hyperactivity–Impulsivity (HI) scales were used as dependent measures.¹ Coefficient alphas obtained in this study indicated acceptable internal consistency for IA (.91) and HI (.84) scales.

The Hollingshead index was used to measure SES. Each participant was asked to report the highest occupational level in the household, which was converted to an index score based on Hollingshead (1975). Indices ranged from 10 to 90, with higher scores indicative of higher SES.

Procedure

Participants were recruited from community organizations (i.e., PTA, faith-based institutions). Email announcements and letters were sent to relevant groups that briefly described the purpose of the project, the time investment required, and contact information to answer any questions. Additional participants were also included through the efforts of a professor teaching an undergraduate course at a Midwestern university, a high school research program designed for juniors and seniors located in suburban New York City, and a hockey league for elementary-aged children living in suburban cities throughout Northern Virginia. Parents were compensated with dinner or a US$5.00 gift card to a national retail store.

Recruitment and data collection took place between November 2010 and August 2013. Each maternal caregiver who agreed to participate and satisfied the inclusion criteria was informed that she was being asked to participate in a study about children’s behavior. As all maternal caregivers who volunteered to participate satisfied the inclusion criteria, no participants were excluded from the study.

Each participant completed an informed consent form and demographic information sheet, as described previously. After random assignment, they were given the following instructions:

You will be asked to watch a videotape of a child’s behavior. After you watch the video, you will be asked to fill out a form that has 18 questions on it about children’s behavior. Please choose the best answer, which ranges from 0 (never/rarely) to 3 (very often) for each question based on the video you just watched.

Participants then watched the assigned videotape and completed the ARS-IV. Data collection took place in private rooms in various locations in the local community, including a faith-based institution, public school, public hockey rink, and private residences.

Two separate videotapes were produced of a Black boy and a White boy exhibiting behaviors associated with ADHD. The two boys were child actors without ADHD who were paid to participate in the videotapes and who were of the same general age (10 years old) and build. To make the vignettes as realistic as possible, the children were not given explicit scripts to follow but were instructed to engage in disruptive, inattentive, impulsive, and physically active behavior and to engage in these behaviors more than the comparison children. Both children were videotaped in a semistructured setting (e.g., free play time with at least one other peer and/or adult who are of the same race as the target child) and meal time with adult and peer (both of the same race as the target child) where there were specific behavioral expectations. In this setting, the target children were often interrupting conversations, nonresponsive to adult requests, and out of their seats. Both tapes were edited such that time spent in free play and meal settings was approximately 6 min and 30 s to produce a total vignette of 13 min.

Several procedures were used to (a) ensure that children in the videotapes displayed behaviors indicative of ADHD and (b) that child behaviors were equivalent across the two versions of videotape. First, to obtain consensus that the videotapes were indicative of ADHD behavior, a panel of experts that included seven Black and White advanced doctoral students in school psychology and school psychology interns working in a suburban Washington, D.C., school system watched the recording of either the Black or White child. Each expert was given a 12-item questionnaire to assess the behavior of the target child in relation to the peer with whom the target child was interacting. Consensus was achieved as 100% of the experts agreed that both the Black and White peer comparisons’ behaviors were less indicative of ADHD relative to the target child. Similarly, the experts agreed that the White (100% agreement) and Black (86% agreement) target children’s behavior was more indicative of ADHD relative to peer comparisons.

To confirm that ADHD-related behaviors were equivalent across vignettes, a White male who was an advanced doctoral student in school psychology coded the boys’ behaviors using the Behavior Observation System for Students (BOSS; Shapiro, 2011). A second school psychology graduate student (Asian American female) independently coded the same videos and served as a reliability observer. Observers had previous training to a level of at least 80% agreement in using the BOSS and were blind to the purpose, hypotheses, and methods of this study. Children’s on-task behavior was characterized as active academic engaged time (AET; writing, answering questions, working on a task) or passive enagaged time (PET; visually oriented to adult instruction), and off-task behavior was classified as off-task motor (OFT-M; being out of seat), off-task verbal (OFT-V; talking or making noises at inappropriate times), or off-task passive (OFT-P; looking away from assigned task).

To determine that children in the vignettes displayed similar levels of behavior, we first ascertained whether observers agreed on the presence and absence of on- and off-task behavior. Interobserver agreement was determined for occurrence, nonoccurrence, and total agreement using the formula, number of agreement intervals divided by the sum of agreement and disagreement intervals. Occurrence, nonoccurrence, and total agreement were 100% for on-task and off-task behavior for both the Black and White children. Next, we compared the number and percentage of observation intervals for each of the five behaviors across the two video vignettes to check for comparability (see Table 2). Although there were slight differences in the numbers and percentages of intervals for each behavior across the two videos, these values were close enough to assume that the boys’ behaviors were highly similar.

Table 2.

Number (and Percentage) of Intervals of On- and Off-Task Behavior for the Black and White Children.

Behavior	Black child	White child
Active engaged time	19 (43.2%)	19 (43.2%)
Passive engaged time	10 (22.7%)	7 (15.9%)
Off-task: Motor	19 (43.2%)	22 (50.0%)
Off-task: Verbal	20 (45.4%)	18 (40.9%)
Off-task: Passive	3 (6.8%)	0 (0%)

Results

A 2 (maternal race) × 2 (child race) MANCOVA was used to assess maternal and child race effects on parent ratings of IA and HI symptomatic behaviors with maternal age and SES as covariates.² Maternal age was included as a covariate because the two groups were significantly different with respect to this variable. There was a significant main effect for maternal race, Wilks’s λ = .91, F(2, 124) = 6.20, p = .003, partial η² = .09. Thus, maternal race accounted for a medium proportion of the variance in ADHD symptom ratings regardless of child race with Black mothers providing significantly higher symptom ratings than White mothers. The main effect of child race, Wilks’s λ = .96, F(2, 124) = 2.64, p = .075, partial η² = .04, as well as the interaction between maternal and child race, Wilks’s λ = .97, F(2, 124) = 1.76, p = .175, partial η² = .03, were not statistically significant.

Separate univariate ANCOVAs were conducted to assess race effects for the IA and HI scales while statistically controlling for SES and maternal age. Statistically significant main effects for maternal race were found for IA, F(1, 125) = 11.80, p = .001, partial η² = .086, and HI, F(1, 125) = 9.58, p = .002, partial η² = .071, with Black mothers providing higher ratings than White mothers on both dimensions (see Figures 1 and 2). No statistically significant main effect for child race, for IA: F(1, 125) = 2.55, p = .11, partial η² = .02; for HI: F(1, 125) = 0.003, p = .96, partial η² = .00, or interaction between child and parent race, for IA: F(1, 125) = 2.58, p = .11, partial η² = .02; for HI: F(1, 125) = 3.43, p = .07, partial η² = .03, was found for either dimension.

Figure 1.

Mean scores on ARS-IV Inattention as a function of maternal and child race.

Figure 2.

Mean scores on ARS-IV Hyperactivity–Impulsivity as a function of maternal and child race.

Discussion

After viewing a 13-min videotape of a boy exhibiting ADHD-related behaviors, Black mothers provided significantly higher ratings of inattentive and hyperactive–impulsive symptoms than did White mothers regardless of child race. The effect of maternal race on symptom ratings was medium in magnitude both in terms of percentage of variance accounted for (partial η² = .086 for IA, partial η² = .071 for HI) and in terms of mean score differences (Cohen’s d = 0.60 for IA, Cohen’s d = 0.59 for HI). Although mean symptom ratings from both Black and White mothers were in the clinically significant range, mean IA and HI ratings obtained from Black mothers were above the 95th percentile using norms for 10-year-old boys (DuPaul, Power, et al., 1998). Alternatively, ratings from White mothers were above the 93rd percentile but below the 95th percentile cutpoint. This difference, while seemingly small, could be meaningful in terms of diagnostic decisions (i.e., depending on the percentile threshold used as a cutoff for ADHD diagnosis) and treatment selection (e.g., possible use of medication as first-line treatment for severe symptoms).

Contrary to expectations, only small, nonstatistically significant effects for child race were found and the interaction between child and maternal race was also associated with small, nonstatistically significant effects. Furthermore, SES did not account for significant variance in group differences in ADHD symptom ratings. Thus, obtained differences in ADHD symptom ratings were influenced almost entirely by maternal race. The fact that racial differences in maternal ratings were found in the current study is certainly consistent with prior studies showing ethnic group differences in teacher (de Ramirez & Shapiro, 2005) and mental health professional (Mann et al., 1992) ratings of child ADHD-related behavior. Clearly cultural, ethnic, and racial backgrounds appear to impact response to behavior rating scales.

Possible Reasons for Racial Differences in ADHD Symptom Ratings

Prior studies have found elevated ADHD symptom reports on rating scales (e.g., Bussing et al., 2008) and diagnostic interviews (Hillemeier, Foster, Heinrichs, Heier, & the Conduct Problems Prevention Research Group, 2007) from parents of Black children relative to parents of White children. However, it is unclear from these studies whether obtained differences were due to maternal race, child race, or their combination. The current study attempted to address this issue by obtaining ratings from two racial groups while controlling for child race. Thus, the overriding question generated by these results is why ADHD symptom ratings are elevated for Black versus White mothers. Given that mothers in both groups observed the same videotape vignettes, racial differences in symptom ratings are clearly not due to actual differences in child behavior. Furthermore, neither maternal age nor SES appeared to account for group differences. It is possible that life experiences and expectations for child behavior may differ between racial groups such that perceptions and ratings, specifically of ADHD symptoms, are subject to response bias based on racial background. One type of response bias is the leniency or severity tendency of informants to have an overly positive or overly critical response set when rating all individuals (Whitcomb & Merrell, 2013). Thus, our results indicate that Black mothers may exhibit a bias toward more severe behavior ratings and/or that White mothers may display a bias toward more lenient behavior ratings. In support of possible response bias on the part of Black mothers, Davison and Ford (2001) asserted that Black mothers may be more focused on children’s physical behaviors and more likely to view high levels of ADHD behavior in a globally negative light or as an indication of an expressive child which is valued in the culture. We were unable to find any published discussions of cultural factors that may impact child behavior ratings provided by White parents. Future studies should address possible factors that could impact ratings of both Black and White mothers as neither group’s responses represent the one accurate standard of behavior by which other groups’ responses must be measured.

It is also possible that behavior ratings could be affected by cultural factors that impact parent perceptions and interpretations of questionnaire items (i.e., symptom descriptions). For example, item response theory (IRT) analyses have shown that structured psychiatric diagnostic interviews may perform differently with respect to ADHD symptoms for Black versus White families even in the presence of the same underlying level of symptomology (Hillemeier et al., 2007). Specifically, Hillemeier et al. found that at the same underlying level of child behavior, parents of White children were more likely to endorse four HI items (e.g., “trouble staying in seat at school,” “always talking at home”) than parents of Black children. Although direction of group differences in the Hillemeier et al. study is contrary to the results of the present investigation, the differential functioning of items across racial groups may point to variations in interpretation of symptom descriptions. Future studies should ask respondents to identify behaviors that they think about when completing specific items to ascertain whether there are systematic differences in item interpretation as a function of race.

Limitations

Several methodological issues limit conclusions based on our findings. First, one HI item (Interrupts or intrudes on others) was inadvertently omitted from the protocol. The omission of this item could have impacted results for the HI factor; however, the internal consistency of this subscale was above .80, and findings for HI were similar to those obtained for the IA subscale. Second, because we did not recruit a nationally representative sample in terms of geographic distribution and SES, the external validity of our results may be limited. Third, the severity of child symptoms in the videos may have impacted our findings. It is possible that a more moderate set of stimuli could have revealed larger informant and target child race effects. Indeed, racial and ethnic differences between parents for mild and borderline cases may have substantial impact and could result in the difference between being diagnosed and not being diagnosed. Fourth, the sample size may have precluded the detection of effect sizes in the small to medium range (e.g., Maternal Race × Child Race interaction effects). Fifth, fathers were not included as participants so the obtained results may not generalize to paternal report of ADHD symptoms. Also, because mothers only viewed behaviors of boys, results cannot be generalized to maternal ratings of girls. Finally, this was an analog study, and different results might have emerged if parents were rating their own children rather than watching videotaped vignettes.

Implications for Practice and Future Research

Consistent with prior findings (e.g., Hillemeier et al., 2007), our results indicate that assessment measures used to identify ADHD may produce quantitatively different results for Black versus White children who have similar treatment needs. Thus, clinicians must not rely on a single method (e.g., rating scale) or respondent (e.g., parent) when screening for or assessing ADHD. The potential for race to impact parent ratings is yet another reason why multimethod, multiple respondent assessment is strongly recommended for diagnostic practice (Pelham et al., 2005). Also, given that cultural differences have been found regarding thresholds for viewing child behavior as a problem (e.g., Roberts, Alegria, Roberts, & Chen, 2005), it is possible for children to receive high ratings for the frequency of ADHD symptomatic behaviors and yet not be viewed as a problem or representative of a disorder. Thus, it is important for clinicians to assess informant perceptions of impairment, not just symptom frequency, when assessing ADHD. Finally, practitioners should consider assessment of parental knowledge regarding nature, etiology, and treatment of ADHD so as to understand beliefs and attitudes that may impact assessment responses (Hillemeier et al., 2007; Olaniyan et al., 2007). When gaps in knowledge or perception are observed, accurate information regarding ADHD symptoms, assessment, and treatment can be provided (Bussing et al., 2012).

There are many directions for future research to build on the current findings. First, given the aforementioned issue of ADHD symptom frequency not necessarily being considered a problem in specific cultural contexts, it would be important for future investigations to ask informants to indicate the degree to which the target child’s behaviors are considered problematic and worthy of clinical attention. Second, parents could be asked about the importance and likelihood of help-seeking for a given child’s symptoms. This would allow examination of possible racial differences in perceptions of mental health need that may impact disparities in ADHD treatment prevalence. Third, rating scales could be modified by eliminating or rewording items (e.g., “talks too much”) that have demonstrated differential functioning across racial groups. Another possibility is to develop and use separate racial norms similar to what is currently done with respect to age and gender. Although this does not directly address possible issues with conceptual equivalence, separate norms may lessen the impact of racial differences on diagnostic decisions. Ultimately, it would be important to develop and evaluate assessment measures that achieve conceptual equivalence across racial groups (Miller et al., 2009). One way to accomplish greater conceptual equivalence may be to provide instructions (e.g., simple definitions of ADHD symptoms, guidelines to rate behavior in relation to children of same age and sex) to parents prior to completing ratings as prior research has shown that prerating instructions may enhance parent–teacher agreement in symptom ratings (Johnston, Weiss, Murray, & Miller, 2013). Finally, the current findings appear most applicable to the assessment of boys with the combined presentation of ADHD. Thus, it would be helpful to investigate whether similar maternal race effects would be found in the context of assessing girls with combined presentation as well as both boys and girls with the inattentive or hyperactive–impulsive presentations of ADHD.

The video vignette methodology employed in the present study could be extended in two ways to further examine the nature and underlying causes of racial differences in ADHD symptom ratings. First, mixed method studies should be conducted to qualitatively examine the cognitions and perceptions associated with ADHD symptom ratings obtained from parents of different racial/ethnic groups. Second, it is also critical to examine the degree to which race may impact ADHD symptom ratings for girls as the subject of ratings and/or with father and teacher respondents.

Conclusion

Maternal race may significantly impact child ADHD symptom ratings wherein higher ratings are provided by Black relative to White mothers. In fact, maternal race appears to be a more important factor than child race in accounting for elevated symptom ratings for Black children. This is important from both applied and research perspectives, because beliefs and attitudes regarding symptoms may ultimately impact parental openness to treatment and compliance with prescribed interventions (Hillemeier et al., 2007). These findings, while intriguing, lead to critical questions regarding the nature of and factors underlying possible racial differences in ADHD symptoms. Given consistent evidence of health disparities across racial groups with respect to ADHD, it is important to understand and address variables related to racial differences and to develop assessment measures that will provide equivalent data and lead to accurate diagnostic decisions across racial and ethnic subgroups.

Footnotes

Acknowledgements

We thank Matthew Gormley and Jennifer Yang for their assistance in providing observational coding data and Dr. Donna Ford for assistance in reviewing the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Charles Barrett earned his PhD in School Psychology from Lehigh University. He is a school psychologist with Loudoun County Public Schools and an Associate Adjunct Professor in the Department of Psychology at Northern Virginia Community College. His professional interests include: cross-cultural assessment of ADHD with black students and cognitive assessment of English Language Learners.

George J. DuPaul, PhD, is Professor of School Psychology at Lehigh University. His research interests include school-based assessment and intervention for students with ADHD and related disorders, early intervention for young children with ADHD, and assessment/treatment for college students with ADHD.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Arnold

L. E.

Elliott

Sachs

Bird

Kraemer

H. C.

Wells

K. C

. . . Wigal

(2003). Effects of ethnicity on treatment attendance, stimulant response/dose, and 14-month outcome in ADHD. Journal of Consulting and Clinical Psychology, 71, 713-727.

Barkley

R. A.

(Ed.). (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York, NY: Guilford Press.

Bussing

Fernandez

Harwood

Hou

Garvan

C. W.

Swanson

J. M.

Eyberg

S. M.

(2008). Parent and teacher SNAP-IV ratings of attention deficit/hyperactivity disorder symptoms: Psychometric properties and normative ratings from a school district sample. Assessment, 15, 317-328.

Bussing

Zima

B. T.

Mason

D. M.

Meyer

J. M.

White

Garvan

C. W.

(2012). ADHD knowledge, perceptions, and information sources: Perspectives from a community sample of adolescents and their parents. Journal of Adolescent Health, 51, 593-600.

Davison

J. C.

Ford

D. Y.

(2001). Perceptions of attention-deficit hyperactivity disorder in one African American community. The Journal of Negro Education, 70, 264-273.

Department of Health and Human Services. (2012, September 12). Information on poverty and income statistics: A summary of 2012 current population survey data (ASPE Issue Brief). Retrieved from http://aspe.hhs.gov/hsp/12/povertyAndIncomeEst/ib.shtml

de Ramirez

R. D.

Shapiro

E. S

. (2005). Effects of student ethnicity on judgments of ADHD symptoms among Hispanic and White teachers. School Psychology Quarterly, 20, 268-287.

10.

Downey

D. B.

Pribesh

(2004). When race matters: Teachers’ evaluations of students’ classroom behavior. Sociology of Education, 77, 267-282.

11.

DuPaul

G. J.

Anastopoulos

A. D.

Power

T. J.

Reid

Ikeda

M. J.

McGoey

K. E.

(1998). Parent ratings of attention-deficit/hyperactivity disorder symptoms: Factor structure and normative data. Journal of Psychopathology and Behavioral Assessment, 20, 83-102.

12.

DuPaul

G. J.

Power

T. J.

Anastopoulos

A. D.

Reid

(1998). ADHD Rating Scale-IV: Checklists, norms, and clinical interpretation. New York, NY: Guilford Press.

13.

Egger

H. L.

Angold

(2006). Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47, 313-337.

14.

Epstein

J. N.

Willoughby

Valencia

E. Y.

Toney

S. T.

Abikoff

H. B.

Arnold

L. E.

Hinshaw

S. P.

(2005). The role of children’s ethnicity in the relationship between teacher ratings of attention-deficit/hyperactivity disorder and observed classroom behavior. Journal of Consulting and Clinical Psychology, 73, 424-434.

15.

Hillemeier

M. M.

Foster

E. M.

Heinrichs

Heier

& the Conduct Problems Prevention Research Group. (2007). Racial differences in parental reports of attention-deficit/hyperactivity disorder behaviors. Journal of Developmental & Behavioral Pediatrics, 28, 353-361.

16.

Hollingshead

A. B.

(1975). Four-factor index of social status. New Haven, CT: Yale University.

17.

Johnston

Weiss

M. D.

Murray

Miller

N. V.

(2013). The effects of instructions on mothers’ ratings of attention-deficit/hyperactivity disorder symptoms in referred children. Journal of Abnormal Child Psychology, 42, 479-488.

18.

C. C.

Howell

R. J.

Cheng

T. C.

(2013). Disparities in Whites’ versus Blacks’ self-rated health: Social status, health-care services, and health behaviors. Journal of Community Health, 38, 727-733.

19.

Mann

E. M.

Ikeda

Mueller

C. W.

Takahashi

Tao

K. T.

Humris

. . . Chin

(1992). Cross-cultural differences in rating hyperactive-disruptive behaviors in children. American Journal of Psychiatry, 149, 1539-1542.

20.

Miller

T. W.

Nigg

J. T.

Miller

R. L.

(2009). Attention deficit hyperactivity disorder in African American children: What can be concluded from the past ten years? Clinical Psychology Review, 29, 77-86.

21.

Morgan

P. L.

Staff

Hillemeier

M. M.

Farkas

Maczuga

(2013). Racial and ethnic disparities in ADHD diagnosis from kindergarten to eighth grade. Pediatrics, 132, 85-93.

22.

Olaniyan

dosReis

Garriett

Mychailyszyn

M. P.

Anixt

Rowe

P. C.

Cheng

T. L.

(2007). Community perspectives of childhood behavioral problems and ADHD among African American parents. Ambulatory Pediatrics, 7, 226-231.

23.

Pelham

W. E.

Jr. Fabiano

G. A.

Massetti

G. M.

(2005). Evidence-based assessment of attention deficit hyperactivity disorder in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 34, 449-476.

24.

Reid

(1995). Assessment of ADHD with culturally different groups: The use of behavior rating scales. School Psychology Review, 24, 537-560.

25.

Roberts

R. E.

Alegria

Roberts

C. R.

Chen

I. G.

(2005). Concordance of reports of mental health functioning by adolescents and their caregivers: A comparison of European, African and Latino Americans. Journal of Nervous and Mental Disease, 193, 528-534.

26.

Shapiro

E. S.

(2011). Academic skills problems, fourth edition workbook. New York, NY: Guilford Press.

27.

Stevens

(1981). Bias in the attribution of hyperkinetic behavior as a function of ethnic identification and socioeconomic status. Psychology in the Schools, 18, 99-106.

28.

Vaughn

A. J.

Hoza

(2013). The incremental utility of behavioral rating scales and a structured diagnostic interview in the assessment of attention-deficit/hyperactivity disorder. Journal of Emotional and Behavioral Disorders, 21, 227-239.

29.

Weisz

J. R.

McCarty

C. A.

(1999). Can we trust parent reports in research on cultural and ethnic differences in child psychopathology? Using the bicultural family design to test parental culture effects. Journal of Abnormal Psychology, 108, 598-605.

30.

Whitcomb

S. A.

Merrell

K. W.

(2013). Behavioral, social, and emotional assessment of children and adolescents. New York, NY: Routledge.