“Commentary: Complex Attention-Deficit Hyperactivity Disorder is Inherently Intersectional”

We see developmental disabilities and behavioral health conditions through an intersectional lens that is both race-conscious and disability-conscious. We trained under the traditional US allopathic medical model at a time that emphasized a biomedical lens to explain differences in health outcomes with only cursory attention to historical and environmental factors that contribute to health outcomes. However, through self-education that focused on expanding our own bio-psycho-social-cultural-spiritual lenses, we have expanded our own views of health, disease, and disparities. We now use a critical historical root cause analytical framework to examine how individual children, families, and communities are affected by the complex interplay of historical and contemporary social, political, educational, legal, environmental, health care, and biological systems.1 Complex attention-deficit hyperactivity disorder (Complex ADHD) is 1 such condition that deserves a historical root cause analysis to elucidate the complex structures that place these patients at risk for experiencing intersectional racism, ableism, and criminalization. In recent years, Society for Developmental and Behavioral Pediatrics (SDBP) has been actively working to increase the understanding of these root causes and to prepare our workforce to more effectively address them in practice. In this special issue of JDBP, guest editors Elizabeth Diekroger and Jason Fogler have curated a collection of cases highlighting patients with Complex ADHD and their health care and educational needs. Among the cases described in this Special Issue, you may read about patients whose conditions remind you of someone you have cared for in your own practice. The editors of this special issue took great care to illustrate the many features and co-occurring conditions that characterize Complex ADHD as defined in our Society's first clinical practice guideline.2 This issue explores Complex ADHD among people with genetic disorders, such as Down syndrome and Smith-Magenis syndrome; congenital heart disease; autism spectrum disorder and behavioral health conditions, including anxiety and depression, all of which are commonly found among people with Complex ADHD. Many of these cases also highlight specific intersectionalities affecting ADHD assessment and care, such as immigration status, chronic health conditions, and minoritized status. People with complex, overlapping, marginalized identities often encounter overlapping discrimination including ableism, racism, sexism, classism (specifically “povertyism,” which is anti-poverty bias), xenophobia, homophobia, religious bigotry, gender bias, weight bias, and more. Black, Native American, Latine, and Asian-American children from low-income families face more obstacles in getting diagnosed with and treated for ADHD.3,4 As a result, children with Complex ADHD are often diagnosed at later ages than their peers without Complex ADHD.5,6 Therefore, when clinicians are caring for patients with Complex ADHD, it is important to think intersectionally and consider root cause. Take into account the complex historical and contemporary societal structures, practices, policies, and traditions that marginalize, disenfranchise, and increase the risks of health care inequities for people with Complex ADHD.5 Being from an economically impoverished family increases the likelihood the child will be diagnosed with ADHD regardless of the child's racial or ethnic background.5,7 The criminalization of ADHD is evident in the public school system, where teachers and school administrators harshly punish students with ADHD more severely than students without ADHD, especially if they receive special education services, are from economically impoverished neighborhoods, and are racially minoritized including Black, Native American, Latine, and Biracial students.8–12 Adults with ADHD have higher unemployment rates, more frequent contact with the criminal legal system, higher rates of anxiety, mood disorders, and substance use disorders, and shorter life expectancy.13,14 We invite you to think intersectionally about all patients you care for with Complex ADHD and recognize the complexity of challenges they face when navigating life, getting an education, and seeking health care. As Developmental-Behavioral Pediatrics (DBP) professionals, we work with interdisciplinary teams to meet individual family needs, inform families about their medical and behavioral treatment options and educational rights under the law, and provide guidance as to how to work with other professionals, including teachers and schools. At the individual level, we can be a beacon of light and advocacy for patients with Complex ADHD and their families to lead healthy, happy, and satisfying lives. At the same time, our teams are often siloed from other community professionals. We encourage you to think critically about systems and policies if we are to have sustained impact beyond the individual patient and family. We encourage you to get involved in your local community, including schools, promote collaboration across systems, and stay abreast of policies at local, state, and federal levels that affect children with Complex ADHD. Developmental-Behavioral Pediatrics professionals have made significant recent contributions to clinical practice and policy recommendations through our professional society, the SDBP, and research network, DBP Research Network (DBPNet). SDBP sponsored our first clinical practice guideline on complex ADHD.2 DBPNet, in collaboration with the Association of University Centers on Disability and a consensus panel, sponsored the Supporting Access for Everyone Initiative for children with neurodevelopmental disabilities.15 Supporting Access for Everyone provides a standard of practice for health care settings to improve equity for youth with neurodevelopmental disabilities; these principles are applicable to other settings, such as schools. These steps are only the beginning. We can be the nidus for disrupting oppressive systems that perpetuate health disparities, poor educational and economic outcomes, and criminalization of Complex ADHD in our practices, communities, and society. Remember: Complex ADHD is inherently intersectional.