Running head: Systematic Review of Disparities in ADHD

A Systematic Review of Disparities in the Diagnosis of Attention Deficit

Hyperactivity Disorder among Children
Carolyn J Schmutz
Clemson University

Systematic Review of Disparities in ADHD

2
Abstract

Purpose
The purpose of this systematic literature review is to describe health disparities in the
diagnosis of ADHD for minority children, explain possible reasons underlying these disparities,
and discuss implications for advanced practice nursing education, practice, and research.
Methods
Articles for this literature review were found searching for English language articles
using electronic databases. The databases searched: CINAHL, Academic Search Complete,
Academic Search Premier, Medline, and Psychology and Behavioral Sciences Collection.
Keywords used: ADHD, children, disparities, and diagnosis. This resulted in the retrieval of 87
articles published from 2002 to 2015, 58 of which were from 2010-2015. Of these 58 articles,
this review focuses on the 10 in journals prominent enough to be available through Clemson
Universitys library collection. An additional six articles were pulled from the years 2002 to
2009, for a total of 16 relevant articles used in this literature review.
Results
ADHD is the most prevalent mental health diagnosis among children in the United States.
However, Hispanic, African American, and children of other race/ethnicities were 56%, 36%,
and 48% less likely, respectively, than whites to be diagnosed. Less than one-third of children
with an ADHD diagnosis are receiving the ideal treatment of both medication and behavioral
therapy.
Conclusions
Wide variations in the diagnosis and treatment of ADHD are seen in the U.S., which
gives reason for further education and research to improve health care practice.

Systematic Review of Disparities in ADHD

A Systematic Review of Disparities in the Diagnosis of Attention Deficit

Hyperactivity Disorder among Children
Introduction
Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder
defined by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes
with functioning or development, according to the American Psychiatric Associations DSM-5
(2013). The DSM-5 diagnostic criteria can be viewed in Appendix A. The number of children
ages four to 17 in the United States (U.S.) who have ever received a diagnosis of ADHD has
increased from seven percent in 1998 to 11 percent in 2011 (Centers for Disease Control and
Prevention [CDC], 2015). ADHD is the most prevalent mental health diagnosis among children
in the U.S. (Morgan, Staff, Hillemeier, Farkas, & Maczuga, 2013). However, less than one-third
of children with an ADHD diagnosis are receiving the preferred treatment of both medication
and behavioral therapy (CDC, 2015). The CDC also reports that the rates of diagnosis from
2003 to 2011 increased by an average of five percent per year. Boys (13.2%) are 2.4 times more
likely to be diagnosed with ADHD than girls (5.6%), and the average age of diagnosis is seven
(2015).
Despite the increasing trend of an ADHD diagnosis among children, minority children
are less likely to be diagnosed with ADHD or receive treatment. According to two studies,
African Americans are the least likely to be diagnosed with ADHD, followed by Hispanics, with
whites by far the most likely to be diagnosed with and treated for ADHD (Zuckermann, Mattox,
Sinche, Blaschke, & Bethell, 2014; Morgan et al., 2013). Research has also shown that the
treatment of ADHD varies geographically, both from state to state and amongst counties
(McDonald & Jalbert, 2013). Several reasons for disparities in the diagnosis of ADHD among

Systematic Review of Disparities in ADHD

children have been proposed, including, lack of access to health care, likelihood of referral by the
school, and decreased ability to pay for treatment (Morgan et al., 2013).
It is important for nurse practitioners (NPs) and other primary health care providers to be
knowledgeable about health disparities in general, and specifically the diagnosis of ADHD in
minority children. According to Gipson, Lance, Albury, Gentner, and Leppert (2015), greater
improvement in academic achievement is seen among children who receive a comprehensive
evaluation, as it increases the likelihood that both ADHD and comorbidities are properly
diagnosed and treated. ADHD has been associated with many issues, including lack of close
relationships, absenteeism, and dropping out of school (Basch, 2011). If children are not being
diagnosed and are therefore left untreated, the implications can continue into adolescence and
adulthood. According to Beard (2015), traffic accidents, smoking, substance abuse, unplanned
pregnancies, emergency room visits, and failed careers are more frequent in adolescence and
adults with ADHD. Dr. Beard states that according to Dr. Daniel Cox, the proper use of a
stimulant can protect from these consequences. NPs should use current evidence-based practice
guidelines in the diagnosis of ADHD, in order to provide the best treatment options and
resources for children and their parents. The purpose of this systematic literature review is to
describe health disparities in the diagnosis of ADHD for minority children, explain possible
reasons underlying these disparities, and discuss implications for advanced practice nursing
education, practice, and research.
Literature Review
Diagnosis
Research consistently demonstrates that disparities exist in the diagnosis of ADHD
among minority populations. According to the census, the population of children under five

Systematic Review of Disparities in ADHD

years old in the U.S. is nearly 50% racial/ethnic minority (Zuckermann et al., 2013). Morgan et
al. (2013) found that from kindergarten to eighth grade, compared to whites, Hispanic, African
American, and children of other races/ethnicities were 56%, 36%, and 48% less likely to receive
a diagnosis of ADHD, respectively. More equitable developmental-behavioral (DB) screening
of children could lead to better treatment and control of ADHD in the minority population.
The identification of ADHD among minority population may be problematic for a variety
of reasons. Racial/ethnic and cultural differences may affect whether a child receives DB
screening, especially in the primary care setting (Zuckermann et al., 2013). Research shows a
correlation between problem recognition and help-seeking among patients and their families
(Thurston, Coates, & Bogart, 2015), which could partially explain racial discrepancies in mental
health care. According to Zuckermann et al. (2013), ideas of normal childhood developmental
vary among cultures. Specifically, African American, Asian, and Latino parents were less likely
to perceive emotional/behavioral issues as being related to mental health. In a study observing
the behavioral risk disparities among the U.S. immigrant population, it was noted that the overall
health of immigrants proved to be better. However, acculturation had a negative impact on the
health status of immigrants, and they often faced linguistic and cultural barriers to health care
access (Singh, Yu, & Kogan, 2013). This racial/ethnic disparity can be mitigated through
education on developmental milestones, mental health issues, and support available in the
primary health care setting.
A problem with decreased access to primary health care among racial/ethnic minorities
has been proven time and time again. Minority families may see less value in routine visits or
seeking treatment within the U.S. health care system due to culture beliefs, historical factors,
and longstanding mistreatment of minorities by health care and educational system, as well as

Systematic Review of Disparities in ADHD

the belief that providers dont understand cultural differences, do not put forth effort to getting
their child services, have negative attitudes toward minorities, or treat minority families poorly
according to Zuckermann et al. (2013). The mental health systems lack of performance for the
minority population may be validation of this belief. In order for NPs to make a difference in the
mental health field, these perceptions must be changed.
The education system can be where the need for mental health services is first perceived,
and according to Mandell, Davis, Bevans, and Guevara (2008), diagnostic criteria for ADHD are
met in 50% of children who receive special education services. The reports of parents and
teachers are used in the diagnostics of ADHD; however, child self-report is rarely used before
the age of 12 (Cohen & Morley, 2009). Children may benefit from being empowered to help
make their own medical decisions at an early age. Mandell et al. (2008) also noted that African
American children were most likely to be labeled emotional disturbance (ED) in the school
system. However, African American parents were less likely to have heard of ADHD, and
therefore did not seek help (Zuckermann et al, 2013).
ADHD comes with many consequences including fewer friendships, absenteeism, and
lower levels of academic success (Basch, 2011). Children with ADHD report more social
rejection by peers, which often results in decreased classroom participation. ADHD also
correlates with an increase in school tardiness and days absent, according to Basch (2011). Both
of these issues lead to decreased academic success, which can lead children with ADHD to drop
out of high school. Basch (2011) reports that dropout rates among children with ADHD is
approximately 2.7 times greater than those without ADHD. These statistics are for children with
diagnosed ADHD, which emphasizes the importance of early and appropriate diagnoses for
children, including those in ethnic minority groups.

Systematic Review of Disparities in ADHD

Treatment
In order to receive proper treatment for ADHD, a diagnosis must be made. Unlike much
of the research, Morley (2010) did not find any racial significance in the diagnosis of ADHD
when clinicians were presented with web-based case studies, but did find that race played an
important role in the treatment of ADHD. According to Cohen and Morley (2009, p. 162), only
about half of those who would potentially benefit from [a stimulant] under this rubric are
receiving it and many of those do not receive a clinically adequate dosage. This statistic may be
due to findings by Berger-Jenkins, McKay, Newcorn, Bannon, and Laraque (2012), which
reported that African American and Hispanic parents distrusted pharmacological treatments of
ADHD and were less likely to keep mental health follow-up appointments, due to this concern.
Specifically, parents who cited Ritalin as a concern were 2.4 times less likely to follow-up and
2.5 times less likely to use any treatment (Berger Jenkins et al., 2012).
Treatment of ADHD varies from state to state according to McDonald and Jalbert, who
noted higher rates of treatment in more urban areas and in counties with larger proportions of
non-Hispanic white residents, less educated populations, higher poverty rates, higher average
expenditures for special education programs in school, and higher prevalence of adults in
treatment (2013, p. 1082). The majority of children received treatment in the primary care
settings; therefore, treatment was positively correlated with the number of pediatricians and
family care practices in the area (McDonald & Jalbert, 2013).
More than half of children with a diagnosis of ADHD are also diagnosed with at least one
comorbid condition (Hinojosa, Hinojosa, Fernandez-Baca, Knapp, Thompson, & Christou,
2012). Oppositional defiant disorder has been found to be the most common comorbid diagnosis
in children with ADHD (Gipson et al., 2015). In order to have better control of the symptoms of

Systematic Review of Disparities in ADHD

ADHD, control of comorbid conditions is vital. Unidentified comorbid conditions and those that
are not well managed correlate with an increase in the severity of ADHD symptoms, worse
patient outcomes, and a decrease in response to treatment (Gipson, et al., 2015). When
providers, parents, and patients better understand the preferred treatment, children with ADHD
enjoy better health and educational outcomes.
Implications for Nursing Education/Practice/Research
Education
NPs should be up to date on the latest research, so that they recognize there are
racial/ethnic disparities in the diagnosis and treatment of ADHD among children. Understanding
of the proper diagnostic tools is imperative, as consistent use of these tools should decrease the
disparities in the diagnosis of ADHD. When minority children are evaluated in the same way as
white children, this disparity should decrease.
Practice
When in practice, knowing the resources that are available to NPs is also important.
Access barriers exist to health services for minorities across the U.S. Those without insurance or
those who distrust the medical community are less likely to seek medical services, especially for
mental health issues. It is important to thoroughly evaluate each patient and to know when a
referral is necessary, as well as what services are available to make follow-up care affordable.
When NPs increase patient and family education, they will help to create a safe environment and
increase the trust of patients.
Research
Further research is needed in order to gain a better understanding of the causes of
disparities in the diagnosis and treatment of ADHD among minorities. It is known that the

Systematic Review of Disparities in ADHD

disparity exists and that minorities face access to care barriers; however, a better understanding
of the causes of these barriers is needed. Research shows correlations and possibilities, but NPs
would benefit from further research in this area.

Systematic Review of Disparities in ADHD

10

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders:
DSM-5. Arlington, VA: American Psychiatric Association.
Basch, C., E. (2011). Inattention and hyperactivity and the achievement gap among urban
minority youth. Journal of School Health, 81(10), 641-649. doi:10.1111/j.1746-1561.
2011.00639.x
Beard, J (2015). Is it ADHD? [PowerPoint slides]. Department of Developmental-Behavioral
Pediatrics, Greenville Health System.
Berger-Jenkins, E., McKay, M., Newcorn, J., Bannon, W., & Laraque, D. (2012). Parent
medication concerns predict underutilization of mental health services for minority children
with ADHD. Clinical Pediatrics, 51(1), 65-76. doi:10.1177/0009922811417286
Centers for Disease Control and Prevention. (2015, March 31). ADHD: data & statistics.
Retrieved June 3, 2015, from http://www.cdc.gov/ncbddd/adhd/data.html
Cohen, E., & Morley, C. (2009). Children, ADHD, and citizenship. Journal Of Medicine &
Philosophy, 34(2), 155-180. doi:10.1093/jmp/jhp013
Gipson, T., T., Lance, E., I., Albury, R., A., Gentner, M., B., & Leppert, M., L. (2015).
Disparities in identification of comorbid diagnoses in children with ADHD. Clinical
Pediatrics, 54(4), 376-381. doi:10.1177/0009922814553434
Hinojosa, M. S., Hinojosa, R., Fernandez-Baca, D., Knapp, C., Thompson, L. A., & Christou, A.
(2012). Racial and ethnic variation in ADHD, comorbid illnesses, and parental strain.
Journal of Health Care for the Poor and Underserved, 23(1), 273-289. doi:10.1353/hpu.
2012.0001
Kendall, J., & Hatton, D. (2002). Racism as a source of health disparity in families with children

Systematic Review of Disparities in ADHD

11

with attention deficit hyperactivity disorder. ANS. Advances In Nursing Science, 25(2), 2239.
Mandell, D. S., Davis, J. K., Bevans, K., & Guevara, J. P. (2008). Ethnic disparities in special
education labeling among children with attention-deficit/hyperactivity disorder. Journal of
Emotional & Behavioral Disorders, 16(1), 42-51. Retrieved from http://search.ebscohost.
com/login.aspx?direct=true&db=rzh&AN=2009878459
Mandell, D. S., Ittenbach, R. F., Levy, S. E., & Pinto-Martin, J. (2007). Disparities in diagnoses
received prior to a diagnosis of autism spectrum disorder. Journal of Autism &
Developmental Disorders, 37(9), 1795-1802. Retrieved from http://search.ebscohost.com/
login.aspx?direct=true&db=rzh&AN=2009687508
Mcdonald, D., & Jalbert, S. (2013). Geographic Variation and Disparity in Stimulant Treatment
of Adults and Children in the United States in 2008. PS Psychiatric Services, 64(11), 10791086.
Morgan, P., L., Staff, J., Hillemeier, M., M., Farkas, G., & Maczuga, S. (2013). Racial and ethnic
disparities in ADHD diagnosis from kindergarten to eighth grade. Pediatrics, 132(1), 85-93.
doi:10.1542/peds.2012-2390
Morley, C. P. (2010). The effects of patient characteristics on ADHD diagnosis and treatment: A
factorial study of family physicians. BMC Family Practice, 11, 10p. doi:10.1186/14712296-11-11
Morley, C., P. (2010). Disparities in ADHD assessment, diagnosis, and treatment. International
Journal of Psychiatry in Medicine, 40(4), 383-389. doi:10.2190/PM.40.4.b
SINGH, G. K., YU, S. M., & KOGAN, M. D. (2013). Health, chronic conditions, and behavioral
risk disparities among U.S. immigrant children and adolescents. Public Health Reports,

Systematic Review of Disparities in ADHD

12

128(6), 463-479. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=hc

h&AN=91967641
Stern, H. P., & Stern, T. P. (2002). When children with attention-deficit/hyperactivity disorder
become adults. Southern Medical Journal, 95(9), 985-991.
Thurston, I. B., Phares, V., Coates, E. E., & Bogart, L. M. (2015). Child problem recognition and
help-seeking intentions among black and white parents. Journal of Clinical Child and
Adolescent Psychology: The Official Journal for the Society of Clinical Child and
Adolescent Psychology, American Psychological Association, Division 53, 44(4), 604-615.
doi:10.1080/15374416.2014.883929
Zuckerman, K. E., Mattox, K. M., Sinche, B. K., Blaschke, G. S., & Bethell, C. (2014). Racial,
ethnic, and language disparities in early childhood Developmental/Behavioral evaluations:
A narrative review. Clinical Pediatrics, 53(7), 619-631. doi:10.1177/0009922813501378

Systematic Review of Disparities in ADHD

13

Appendix A
Diagnostic Criteria for ADHD reprinted from the DSM-5, (2013, p. 59-60)
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to
a degree that is inconsistent with developmental level and that negatively impacts directly on
social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or failure to understand tasks or instructions. For older adolescents and adults (age
17 and older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at
work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty
remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even
in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or
duties in the workplace (e.g., starts tasks but quickly loses focus and is easily side-tracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential
tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has
poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(e.g., schoolwork or homework; for older adolescents and adults, preparing reports,
completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books,
tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may
include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).
2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with developmental level and that
negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or a failure to understand tasks or instructions. For older adolescents and adults
(age 17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her
place in the classroom, in the office or other workplace, or in other situations that require
remaining in place).

Systematic Review of Disparities in ADHD

14

c. Often runs about or climbs in situations where it is inappropriate (Note: In adolescents or

adults may be limited to feeling restless).
d. Often unable to play or engage in leisure activities quietly.
e. Is often "on the go" acting as if "driven by a motor" (e.g., is unable to be or
uncomfortable being still for extended time, as in restaurants, meetings; may be experienced
by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes peoples
sentences; cannot wait for turn in conversation).
h. Often has trouble waiting his/her turn. (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities;
may start using other peoples things without asking or receiving permission; for adolescents
and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings
(e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication
or withdrawal).