Abstract
Objective: The purpose of this content analysis study was to characterize patterns of research on Black youth with ADHD. Method: Relevant articles were identified through searching psychology and medical databases and cross-referencing citations in previously published review articles. The 204 empirical articles included in this study (1) were conducted in the United States, (2) had a predominantly child or adolescent sample, (3) had more than 80% Black youth/families in the study sample and/or conducted separate analyses for Black youth/families, and (4) examined ADHD symptoms or diagnoses. Articles were categorized into five primary content areas: Assessment, Treatment, Perceptions, Prevalence, and Associated Correlates. Journal characteristics, sample characteristics, and methodological characteristics are presented across these content areas. Results: Findings show a relatively low representation of Black youth with ADHD in the literature, with most studies using race comparative approaches and secondary data analyses, and many being published in medical journals. Conclusion: Based on these results, changes are recommended both at the individual study and broader systems levels (e.g., funding agencies). More research, funding, and publications centering Black youth with ADHD are vital to understanding and correcting long-standing health disparities for this community.
The COVID-19 pandemic amidst the ongoing Black Lives Matter movement highlighted the role that structural racism plays in the health and mental health disparities for Black people living in the United States, and renewed demands for racial justice. Impacts of structural racism and systemic oppression were amplified by disparities in risks from pre-existing health conditions (Anderson et al., 2023) and higher rates of COVID mortality in Black communities (Ramprasad et al., 2022), as well as the increased academic opportunity gap among Black youth (Goldhaber et al., 2022). The American Psychological Association (APA, 2021) issued an apology for its role in perpetuating racism and racial discrimination, and has since adopted a comprehensive action plan to combat racism in the field of psychology (APA, 2023). Despite specific calls and strategies by Buchanan et al. (2021) to combat racism in psychological research and by Galán et al. (2021) to address institutional practices in clinical psychology training, there remains a significant gap in acknowledging and addressing the mental health of Black Americans. This paper aims to shed light on this disparity by examining the literature on ADHD, the most prevalent childhood mental health condition in the U.S. (Center for Disease Control and Prevention, 2022), and its understanding of the unique experiences of Black youth and their families. Further underscoring the dearth of research highlighted by previous reviews on Black children with ADHD (Miller et al., 2009; Samuel et al., 1997), the current paper aims to appraise the existing body of research and offer recommendations for future research and systemic change.
Current State of Black Youth’s Mental Health
Black youth are more likely to be impacted by sociocultural risk factors (e.g., illness, poverty, and discrimination; Reeves et al., 2016) that place them at risk for mental health problems. However, the literature on racial disparities in prevalence of psychological disorders is mixed. For example, compared to White youth, Black youth report lower rates of anxiety and depression, and Black youth with internalizing symptoms are more likely to be underdiagnosed and treated. Conversely, Black youth are more likely to be diagnosed with disruptive and conduct disorders compared to White youth (Bitsko et al., 2022). Although Black youth have historically been diagnosed with ADHD less often than their White counterparts (Miller et al., 2009), more recent data suggest comparable rates (Cénat et al, 2024). Researchers have attempted to explain these mental health disparities in several ways. First, it has been posited that distinctive protective and promotive factors specific to Black youth, such as racial identity, racial socialization, and worldview/cultural orientation may help to mitigate the deleterious effects of adversity and promote positive emotional well-being (S. C. Jones & Neblett, 2016). On the other hand, these disparities in prevalence rates may be attributed to variations in how mental health disorders, particularly depression and anxiety, may manifest in Black youth (Choi & Park, 2006). There is also evidence to suggest that racial bias in the assessment of mental health disorders in Black youth leads to the misinterpretation of symptoms, resulting in under/over-identification or misdiagnosis (Liang et al., 2016).
In contrast to these mixed prevalence rates of mental health conditions, Black youth in the U.S. are less likely to receive mental health services (Luna et al., 2023; Rodgers et al., 2022). These disparities in service use have been linked to systemic inequities that reduce their access to mental health services (Burkett, 2017). Unfortunately, when Black youth do not receive adequate mental health treatment, they are at risk of experiencing increasingly severe academic, social, and functional challenges (Porche et al., 2011). Therefore, careful attention to the unique mental health needs for Black youth is critical for their optimal positive well being.
ADHD in Black Youth
ADHD is the most common childhood mental health condition in the U.S. with 9.4% lifetime and 8.4% current diagnosis rates (Center for Disease Control and Prevention, 2022). It is also one of the most researched childhood psychological conditions, with upwards of 75,000 studies when ADHD is searched in PsycInfo. Given marked difficulties with inattention and hyperactivity, youth with ADHD are also at risk for short- and long-term negative outcomes, including legal, medical, and comorbid mental health problems. While we know much information generally about the etiology, causes, and associated outcomes with ADHD, relatively less is understood about how ADHD manifests and presents in Black youth and their experiences with ADHD. A general pattern of findings across assessment studies over time suggest a trend that Black youth consistently receive higher symptom ratings than their White counterparts (e.g., DuPaul et al., 2016). Paradoxically, they are less likely to receive diagnoses and undergo treatment for ADHD (Glasofer & Dingley, 2022). Additionally, persistent disparities in treatment outcomes for children and youth with ADHD have been observed, emphasizing the contrast between Black and White youth in the United States. Black youth exhibit lower rates of initiation and higher rates of discontinuation in ADHD treatment when compared to their White counterparts (Berger-Jenkins et al., 2012; Kamimura-Nishimura et al., 2023; B. W. Schneider et al., 2013). This discrepancy is particularly concerning given that ADHD-related impairments can significantly compound challenges for Black youth, who are already susceptible to heightened academic, social, and functional difficulties (Cauce et al., 2002; Porche et al., 2011). However, Black youth continue to be underrepresented in the ADHD literature as demonstrated by previous literature (Glasofer & Dingley, 2022; Miller et al., 2009; Samuel et al., 1997) and the current study.
Aims of the Current Study
There are three seminal reviews on ADHD in Black youth. In the first major literature review, Samuel et al. (1997) found sparse and inconclusive findings regarding the role of race in ADHD; they only identified 16 articles related to ADHD in Black youth with even fewer with race as a primary focus. Ten years later, Miller et al. (2009) published an updated review that included more studies (n = 74) and were able better elucidate the experiences of Black youth with ADHD. However, Miller et al. (2009) also concluded that there were several areas of research that deserved attention, such as the role of risk factors in ADHD and how culture and racial identity influence the perceptions and management of ADHD in Black families. More recently, Glasofer and Dingley (2022) reviewed 41 studies specifically to examine diagnostic and treatment disparities of ADHD between Black and White youth and concluded that Black youth with ADHD are less likely to be diagnosed and treated with medication. The increase in the number of relevant articles serves as an indication that the field has started to see the importance in understanding Black youth and families’ experiences with having ADHD. However, 15 years have passed since the last comprehensive review of the literature on Black youth with ADHD (Miller et al., 2009) because Glasofer and Dingley (2022) solely focused on disparities in diagnosis and treatment. Therefore, an updated review is essential to evaluate the progress toward reducing mental health disparities of ADHD in Black youth.
Further, despite increasing numbers of studies examining this topic, there has been no attempt to content analyze the existing literature. While the previous systematic reviews have been useful in highlighting what we know about Black youth and ADHD, they do not specifically provide information about the patterns of existing scholarship, which can highlight important gaps in the extant literature (Krippendorf, 2013). Even with increases in research on ADHD in Black youth, this literature remains far too small to inform appropriate diagnosis and treatment for Black youth and their families. Therefore, a content analysis will help to characterize the existing body of literature which in turn can point to key gaps in knowledge to better serve Black youth with ADHD. For example, it would be useful to determine whether research on ADHD in Black youth has been published more in certain types of journals (e.g., Psychiatry, Psychology, and Social Work), and whether research has focused on particular types of datasets (e.g., secondary data). Thus, this paper aims to (1) provide quantitative content analyses to reveal patterns in the existing literature and to highlight knowledge gaps in Black youth with ADHD, and (2) to provide suggestions for future research as well as for structural changes in ADHD research with Black youth. As F. G. Brown (1969) noted, it is important for the field to periodically “take a look at itself-where it has been, where it is now, and where it is going.”
Method
Research Team
This project was co-led by two doctoral candidates in clinical psychology under the supervision of two tenured faculty members in Departments of Psychology. Two of the raters were affiliated with a public research university in the Southeastern region and two of the raters were affiliated with a public research university in the Northeastern region of the United States. All authors on this project have expertise in the study of and clinical practice with youth with ADHD, and two have expertise in Black families and mental health.
Procedure
An initial search was conducted on PsycInfo and PubMed that included peer-reviewed journal articles and dissertation theses 1 written in English between 1970 and June 2023. Search terms included “ADHD,” “Attention Deficit Hyperactivity Disorder,” “Attention Deficit Disorder,” “hyperkinetic,” cross-listed with “Black,” “African American,” and “Afro.” Articles cited in previously published review papers were cross-referenced to identify additional studies on Black youth with ADHD not identified in the search. Of the 427 articles resulting from this search, the two first authors reviewed all abstracts and categorized each article for inclusion and exclusion criteria. Then, the last two authors reviewed abstracts in each category to determine whether each article was appropriately selected for inclusion and exclusion. Inclusion criteria included empirical studies conducted in the United States with predominantly Black youth (80% or more), or studies where separate analyses were conducted by race such that conclusions could be drawn about Black youth with ADHD. Studies that examined ADHD symptoms on a continuum (e.g., hyperactivity, inattention, and impulsivity) were included along with studies that examined ADHD as a categorical diagnosis. Studies that examined perceptions of ADHD, even if they did not include actual Black youth with ADHD (e.g., vignettes), were included if they presented findings about how providers, educators, or Black caregivers perceive Black youths’ ADHD symptoms. Only studies about childhood ADHD were included; thus, epidemiological studies that examined childhood psychopathology more broadly and studies that examined ADHD in Black adults were excluded. These methods and inclusion criteria were informed by previous studies with similar goals (e.g., M. K. Jones et al., 2018; Miller et al., 2009).
Analytic Plan
Using a previously published content analysis as a model (M. K. Jones et al., 2018) and our shared expertise of the literature, we established five content areas: Assessment, Treatment, Perceptions, Prevalence, and Associated Correlates of ADHD. For studies that fit under two or more content areas, we discussed and reached consensus for a single primary content area per study. Categorization of studies according to primary content area aimed to shed light to which empirical area has been studied more or less frequently to understand Black youth with ADHD. Studies in the Assessment content area focused on the process of diagnostic assessments of ADHD in Black youth. Studies in the Treatment content area included pharmacological and behavioral interventions for Black youth with ADHD. Studies in the Perceptions content area focused on youth, caregiver, medical provider, and teacher perceptions of ADHD symptoms, diagnosis, and treatment in Black youth. Studies in the Prevalence content area focused on documenting the prevalence rates of ADHD among Black youth. Lastly, studies in the Associated Correlates content area focused on factors associated with ADHD diagnoses or symptoms in Black youth. The two first authors reviewed each study of the 204 studies carefully to extract the following information: journal characteristics (e.g., impact factor, discipline), sample characteristics (e.g., age range, recruitment methods, and percentage of Black youth with ADHD included in the study), and methodological characteristics (e.g., study design, analytic methods, and deficit or strength-based framework).
Results
Content Areas
Supplemental Table 1 includes a list of all 204 reviewed articles by content area. The Treatment content area (n = 57) included the most number of studies followed by Assessment (n = 43), Associated Correlates (n = 43), Perceptions (n = 32), and Prevalence (n = 29) content areas.
Treatment
Studies in the Treatment content area examined different aspects of ADHD treatment for Black youth and families. These studies aimed to characterize Black caregivers’ help-seeking behaviors around their children’s ADHD (e.g., Bussing, Koro-Ljungberg et al., 2005; dosReis et al., 2007; Saulsberry et al., 2020) and their use of pharmacological (e.g., Bruckner et al., 2012; Garfield et al., 2015; Graves & Serpell, 2013; Frey, 2020) or psychosocial (Locke et al., 2017) interventions. Studies in the Treatment content area also examined efficacy of different pharmacological treatments (Arnold et al., 2003; Hazel-Fernandez et al., 2006; Starr & Kemner, 2005) and psychosocial interventions (H. A. Jones et al., 2010; Jurbergs et al., 2010; Meinzer et al, 2023; Mohn, 2019; Sibley et al., 2022) for Black youth with ADHD.
Assessment
Studies in the Assessment content area characterized the diagnostic assessment processes for Black youth with ADHD. These studies examined the likelihood of Black youth being diagnosed with ADHD (e.g., Baglivio et al., 2017; Bax et al., 2019; Mandell et al., 2008; Morgan et al., 2014) and informant discrepancies in ADHD symptom ratings of Black youth (e.g., Bussing et al., 2008; DuPaul et al., 2016; S. W. Evans et al., 2013; Reid et al., 1998; Wexler et al., 2022). Some studies investigated the diagnostic validity of different ADHD rating scales when used with Black youth (e.g., Andretta et al., 2013; Bidaut-Russell et al., 1998; Costantino et al., 1991; Purpura et al., 2010; Reid et al., 2001; Shanahan, 2009).
Associated Correlates
Studies in the Associated Correlates content area examined a wide range of correlates with ADHD. The studies in this content area examined different risk factors (e.g., exposures to environmental toxins; Morrow et al., 2009; Perera et al., 2018), comorbidity with other externalizing and internalizing disorders (e.g., Casseus, 2022; Walls, 2007), different domains of cognitive and behavioral functioning (e.g., Dvorsky et al., 2021; Zalot et al., 2009), and parenting and social support outcomes (e.g., parenting stress; Hinojosa et al., 2012) for Black youth with ADHD.
Perceptions
Studies in the Perceptions content area examined subjective perceptions of ADHD in Black youth among caregivers and providers. Many of these studies characterized Black parents’ conceptualization of ADHD such as its etiology (e.g., Bussing et al., 2007, 2012; Bussing, Gary, et al., 2003; Bussing, Schoenberg, & Perwien, 1998) and the process of navigating services for their children’s ADHD (e.g., A. Evans, 2019; Hatt, 2009; Mychailyszyn et al., 2008; Olukanni, 2015; Von Raub, 2020; Wilkerson, 2021). Several studies investigated parental perceptions about ADHD treatment (e.g., Barnard-Brak & To, 2009; Bussing et al., 2007; Carpenter-Song, 2009; Stief, 2003) and potential impacts of teachers’ racial bias in ratings of Black youth’s ADHD symptoms (e.g., Kang & Harvey, 2020; Mead, 2010).
Prevalence
Finally in the Prevalence content area, studies used different sampling strategies and analytical methods to document similar, higher, or lower prevalence of ADHD in Black youth.
Journal Characteristics
Of the 204 studies that met inclusion criteria, 163 were published articles in peer-reviewed journals, 36 were unpublished theses/dissertations, and 5 were government reports. Journal characteristics (impact factor and subject category) were obtained via Journal Citation Reports. For journals that were not listed, their Social Sciences Citation Index (SSCI) or the Science Citation Index Expanded (SCIE) subject category was inferred from similar journals and the impact factor was obtained from journal websites. The median impact factor for all published studies was 3.30 (SD = 4.74, range = 0.34 - 26.1). Studies were published most frequently in pediatric (n = 30) journals, followed by psychiatry (n = 29), and clinical psychology (n = 23) journals.
Sample Characteristics
Demographic Composition
The sample sizes varied across studies and ranged from single case studies (n = 1, e.g., Fabiano & Pelham, 2003) to national epidemiological studies (n = 536,352, Garfield et al., 2015). Out of the 204 studies, only 39 studies (19%), including 5 case studies, examined samples of exclusively Black children. For the remaining studies, the percentage of Black children ranged from 2.6% (Nolan et al., 2001) to 98% (Bain & Pelletier, 1999). Especially in the two service utilization content areas, Assessment and Treatment, the proportion of Black children with ADHD compared to the total sample remained consistently low (Figure 1). Of note, 18 studies (9%) exclusively included parents, teachers, school psychologists, and/or medical professionals as study samples, primarily to examine the pattern of referrals and discrepancies in symptom ratings for Black youth.
Proportion of Black children with ADHD diagnoses.
Recruitment Methods
Most studies (n = 63; 31%) reported findings about youth recruited from clinical settings (e.g., hospitals; community mental health clinics). Fifteen of them specifically reported findings from Medicaid claims data (Cummings et al., 2017; Davis et al., 2019; dosReis et al., 2001; Garfield et al., 2015; Heneghan et al., 2013; Ibe, 2010; Ji et al., 2018; Locke et al., 2017; Mandell et al., 2008; Marcus et al., 2008; Moran et al., 2019; Saloner et al., 2013; Soltis et al., 2017; Stein et al., 2012; Yin et al., 2022). Fifty-two studies (25%) reported findings about youth recruited from schools, 15 studies (7%) from youth in community settings (e.g., child care centers, Harvey et al., 2013; foster care agencies, Herd et al., 2023), and 5 studies (2%) reported findings about youth recruited from forensic and juvenile legal settings. Forty-two studies (21%) reported findings from nationally representative epidemiological surveys (e.g., National Survey of Children’s Health; Collins & Cleary, 2016) and 10 studies (5%) reported mostly vignette study findings exclusively from providers (e.g., physicians; Garland et al., 2015). Seventeen studies (8%) reported findings from samples recruited from a combination of these sources.
Overlapping Samples
Across the content areas, there were several overlapping samples. Ten studies reported findings from a longitudinal study on ADHD detection and service use in the Southeastern region of the U.S. starting in 1998 (Bussing et al., 2007, 2008, 2012, 2016; Bussing, Gary, et al., 2003; Bussing, Koro-Ljungberg, et al., 2005; Bussing, Zima, et al., 2005; Bussing, Zima, Gary, & Garvan, 2003; Koro-Ljungberg et al., 2008; Murray et al., 2009). Two studies by the same lead author described similar screening and recruitment procedures with samples of White or Black second to fourth grade youth with learning or social-emotional problems (Bussing, Schoenberg, & Perwien, 1998; Bussing, Schoenberg, Rogers, et al., 1998). Four studies reported findings from the MTA Study (Arnold et al., 2003; Epstein et al., 2005; H. A. Jones et al., 2010; Reed et al., 2017). Other longitudinal studies from which findings were reported included the ADHD Teen Integrative Data Analysis Longitudinal (TIDAL) dataset (Coxe et al., 2021; Sibley et al., 2022), the Special Education Elementary Longitudinal Study (SEELS; Barnard-Brak & To, 2009; Graves & Serpell, 2013), Healthy Passages (Coker et al., 2009, 2016), and the Early Childhood Longitudinal Study (Morgan et al., 2013, 2014; H. Schneider & Eisenberg, 2006). Four studies reported data collected from the same genetics center at a large hospital (Liu et al., 2020, 2021; Liu, Qu, Chang, et al., 2022; Liu, Qu, Mentch, et al., 2022). DuPaul et al. (2016) and DuPaul et al. (2020) both used the same sample of nationally represented parents and youth. Two dissertations (Goldstein, 2001; Williams, 2003) both presented data from four public schools in the mid-Atlantic region of the U.S., and two studies published by R. T. Brown and Sexson (1988, 1989) used the same sample of Black male adolescents. Finally, several studies reported on different iterations of nationally represented epidemiological surveys including seven from the National Survey of Children’s Health (Casseus, 2022; Collins & Cleary, 2016; Frey, 2020; Hinojosa et al., 2012, 2020; Walls et al., 2018; Weller et al., 2018), five from the National Health Interview Survey (Pastor et al., 2015; Pastor & Reuben, 2002, 2005, 2008; Xu et al., 2018), and four from the Medical Expenditure Panel Survey (C. E. Evans, 2011; Hudson et al., 2007; Stevens et al., 2005; Yang et al., 2022).
Methodological Characteristics
ADHD Characterization
The majority of articles used categorical diagnosis of ADHD (n = 150; 74%), and 52 articles (25%) examined ADHD symptoms as dimensional traits. Two studies (1%) examined both categorical diagnoses and dimensional symptoms of ADHD.
Analytic Methods
Most studies (n = 127, 62%) presented findings from secondary data analyses, while 77 (19%) studies presented original data collected to explore questions about Black youth with ADHD. Of these, six studies (Beckford, 2016; Cione et al., 2015; Costigan, 2001; Fabiano & Pelham, 2003; Hatt, 2009; Mohn, 2019) were single case studies and one study was a case study of two Black children (Lee, 2017). The majority of studies (n = 169, 83%) presented findings from quantitative analyses and 35 studies (17%) presented findings from qualitative or mixed method analyses. Most studies (n = 145, 71%) used race comparative approaches to report findings on Black youth compared to White youth, while 51 studies (25%) presented within-group findings. Only two studies from the same research team utilized community-engaged research methods. such as using input from community members to inform research design (Meinzer et al., 2023; Shippen et al., 2022).
Studies were coded for deficit- and/or strength-oriented frameworks. Deficit-orientation was operationalized as explicit study hypotheses that predicted deficits and impairments specific to Black youth and families, and there were 21 studies (10%) with this framework (Andretta et al., 2013; Arnold et al., 2003; Assari & Caldwell, 2019; Awatefe, 2016; Bain & Pelletier, 1999; Behnken et al., 2014; R. T. Brown et al., 1991; Coles, 1997; Costigan, 2001; Grundy, 2016; Hunt et al., 2017; Merrill et al., 2021; Morrow et al., 2009; Perera et al., 2018; Rabiner et al., 2005; Saloner et al., 2013; Samuel et al., 1998, 1999; Soltis et al., 2017; Unger et al., 1997; Zalot et al., 2009). Strength-orientation was operationalized by study hypotheses or variables that considered protective factors for Black youth and families, such as positive self-esteem (Houck et al., 2011) and ethnic identity (Koro-Ljungberg et al., 2008). Ten studies (5%) were identified as strength-oriented (Behnken et al., 2014; Bussing, Zima, Gary, Mason, et al., 2003; Hazel-Fernandez et al., 2006; Houck et al., 2011; Jurbergs et al., 2010; Koro-Ljungberg et al., 2008; Mohn, 2019; Montgomery, 2007; Saulsberry et al., 2020; Shippen et al., 2022).
Discussion
The current paper presents the first quantitative content analysis of empirical research on Black youth with ADHD between 1972 and June 2023. The goal of this paper was to characterize the state of the literature that focused on Black youth and their families’ experiences of having ADHD. The findings yielded several meaningful patterns that offer valuable insights for guiding future research in this area.
The pattern of methodological and sample characteristics observed indicates that Black youth’s experiences with ADHD may be an afterthought in ADHD research. The majority of studies (62%) presented results from secondary data analyses rather than from data collected specifically to examine the experiences of Black youth with ADHD and their families. Further, up to 50 studies (25%) had potentially overlapping samples, which raises questions about the actual representation of Black children with ADHD across the 204 identified studies. Especially in the two service utilization content areas (Assessment and Treatment), the proportion of Black children with ADHD in study samples compared to the total number of children with ADHD in each study remained consistently low (Figure 1). These findings suggest a need for more research that is designed to intentionally center Black youth with ADHD and their families.
Although secondary data analyses are often more accessible and convenient for publication, most large studies were not designed purposefully to better understand and better serve Black youth with ADHD. If this trend continues, Black youth will remain a minority of the study sample and be compared to White youth in most secondary datasets. In fact, the majority of studies (71%) identified in this paper used race comparative methods. Such comparative designs may inadvertently perpetuate the oppressive notion that the White experience is the norm in the United States, while the Black experience only belongs in the margins. In other subject areas of psychology (e.g., Black youth and suicidality), researchers have suggested a “ground zero” approach to studying Black youth due to lack of representation of Black youth in research pertaining to their perspective fields (Sheftall & Miller, 2021). According to the “ground zero” approach, studies should begin anew, with a fresh perspective, to identify risk and protective factors related to ADHD in Black youth. By doing so, researchers can aim to move away from the traditional White-centric viewpoint and create a more comprehensive understanding of the experiences and needs of Black youth with ADHD.
This also means that conventional quantitative methods must be expanded to include qualitative methods that give voice to culturally- and racially-relevant variables. Findings of the current paper showed that most identified studies presented findings on quantitative methods (83%) while a few presented results from qualitative (15%) or mixed-methods (2%). Relatedly, the primary evidence-based psychosocial treatment for young children with ADHD is behavioral parent training, which was designed with primarily White families. There is a vast developmental literature on racial differences in parenting and child outcomes (e.g., Kang et al., 2023). However, little research has been conducted on the cultural congruence of behavioral parent training with Black families of children with ADHD, even though baseline parenting differences by race have been found (e.g., H. A. Jones et al., 2010). Therefore, more studies designed intentionally and purposefully to center Black youth and their families will enrich the ADHD literature and better inform culturally-sensitive treatment for Black youth with ADHD.
Although not explicitly investigated through this content analysis, specific studies have called for more research around the mechanisms of persistent racial disparities in the rates of ADHD diagnosis and treatment (e.g., Glasofer & Dingley, 2022). Many studies in the service utilization (i.e., assessment and treatment) and prevalence content areas merely concluded racial differences in Black children diagnosed and treated for ADHD (e.g., Baglivio et al., 2017; Bruckner et al., 2012; Merikangas et al., 2011), while only a few attempted to explain the mechanisms underlying those disparities (e.g., Davison & Ford, 2001; Graves et al., 2013). Racial categories, as socially constructed distinctions between groups of individuals, do not stand independently to justify differences in outcomes (Betancourt & Lopez, 1993; Helms et al., 2005). As such, more research should contextualize these racial disparities in prevalence and service utilization for ADHD among Black youth within generations of oppression and structural racism in order to promote racially equitable mental healthcare for Black youth. Although some studies examined the impact of interpersonal racism (i.e., individual racial bias; Kang & Harvey, 2020; Mead, 2010) on these racial disparities, even fewer studies considered the impacts of institutional and structural racism on disparities in ADHD prevalence and service utilization. By nature, racism is upheld and perpetuated by institutional policies and practices for example within the legal, educational, and healthcare systems (Delgado & Stefancic, 2017). To truly understand and rectify racial disparities in Black children being overidentified with yet undertreated for ADHD symptoms, the field of clinical child psychology must move beyond mere documentation of racial differences to a more comprehensive understanding of the pervasive impacts of structural racism and longstanding oppression on Black families’ access to and utilization of mental health services (Shim, 2021).
Potential Systemic Contributors to Current Findings
There was a notable dearth of research on Black youth with ADHD. The first seminal review only identified 16 studies (Samuel et al., 1997), the second review identified 74 studies (Miller et al., 2009), and the most recent review identified 41 studies specifically on diagnosis and treatment studies (Glasofer & Dingley, 2022). The current paper used search terms similar to Miller et al. (2009) but also included 36 unpublished dissertations and theses and 5 government reports, and found 204 studies that drew conclusions about Black youth with ADHD and their families. That is, the current paper found 163 peer-reviewed journal articles, which means that only 89 studies were published in the span of 15 years since Miller et al. (2009). This number contrasts with the vast and fast expanding body of ADHD literature of close to 75,000 studies (when ADHD is searched in Psycinfo), pointing to a need for more scholarship focused on Black youth with ADHD. The issue of funding is inherently tied to this lack of scholarship. For example, when we searched for funded research grants that focused specifically on ADHD and Black/African Americans on the National Institutes of Health (NIH) RePorter, only seven relevant grants emerged as funded since 1983, which contrasts with 2,351 funded grants when ADHD is searched alone. Although NIH is not the only federal agency to fund research on ADHD, this data illustrates the point that research intentionally designed to study Black youth with ADHD is severely underfunded compared to the broader ADHD research. Increasing systematic efforts to prioritize this work by major funding agencies is an imperative step to expanding scholarship on Black youth with ADHD.
Another pattern of extant literature identified in this content analysis is the use of deficit-oriented frameworks and sampling strategies. Studies that explicitly hypothesized deficits and impairments unique to Black youth and families were coded as deficit-oriented. For example, Zalot et al. (2009) examined neighborhood disadvantage and conduct problems within a sample of Black youth with ADHD, and Merrill et al. (2021) hypothesized that race (i.e., being Black) would predict impaired health behaviors. Aside from these 21 studies that had explicitly deficit-oriented hypotheses, more studies used sampling strategies that focused on “disadvantaged” groups such as Medicaid patients (e.g., Moran et al., 2019), homeless youth (e.g., Unger et al., 1997), youth in public housing (e.g., Bazargan et al., 2005), and youth in juvenile settings (e.g., Baglivio et al., 2017). These deficit-oriented frameworks and sampling strategies may hold the literature and clinical practice stagnant in only understanding Black youth and families’ experiences through a marginalizing lens. Although convenience sampling has been a longstanding issue in psychological science in failing to capture the nuanced experiences of systemically oppressed and underrepresented populations (Nielsen et al., 2017), our field must put more intentional effort to partner with Black communities to increase their voices and equitable representation in clinical child psychology. To that end, community-based participatory research has been posited to foster intentional community-academic partnerships to promote mutually beneficial collaborations that honors the lived experiences and strengths of a community (Wallerstein & Duran, 2006). This paper only identified 2 studies by the same research team that described using community-engaged research methods and 10 studies that examined strength and protective factors. Future research must re-envision empirical methods and research frameworks to acknowledge the strengths that keep Black communities resilient despite systemic oppression to promote anti-racism in clinical child psychology.
Relatedly, rectifying disparities for researchers who receive research funding is crucial to better understand and serve Black youth with ADHD. Research has consistently shown that scientists’ personal experiences and expertise, coupled with relevant contextual understanding, are instrumental in formulating vital questions, engaging communities, and developing, implementing, and evaluating interventions (Gupta et al., 2023). Despite efforts to address this issue, an analysis of NIH grant success in 2011 revealed a troubling trend: the NIH was less likely to award research grants to Black researchers compared to their White colleagues (Ginther et al., 2011). This disparity persists today, with Black researchers being 40% less likely to be principal investigators than their White colleagues (Nguyen et al., 2023). To effectively tackle these disparities in research representation, it is imperative for not only scholars to conduct more research focused on ADHD in Black youth, but also for funding agencies to bolster funding opportunities for Black scholars whose lived experiences can provide unique insights when conducting innovative research in this topic. By investing in scholarship on ADHD in Black youth and increasing funding for Black investigators, clinical science can become a more equitable and inclusive field.
Publication trends over time suggested growing attention to the topic of Black youth with ADHD, and this increased attention must be sustained. According to our results, there were little to no studies between the 1970s and 1990s, and the number of publications started to increase in the 2000s to the 2010s (Figure 2). A notable spike in the number of published articles occurred after 2020, with 17% (n = 27) of all peer-reviewed articles identified in this study being published between 2021 and June 2023. This acute increase is likely due to the nation’s renewed attention to anti-Black racism and the racial reckoning that followed high-profile cases of state violence, police brutality, and racial health disparities illuminated by the pandemic. This may be a reflection of a phenomenon coined health equity tourism (Lett et al., 2022), in which previously unengaged, yet established scholars co-opt health equity scholarship, often in predatory and temporary manners, in reaction to a spike in national attention to anti-Black racism. However, careful study design, collaboration with the Black community and Black scholars, and continuous interrogation of positionality (Lett et al., 2022) can help sustain this increased attention to health disparities driven by structural racism, particularly for Black youth with ADHD.
Frequency of published studies by year.
Lastly, editorial boards of clinical psychology journals play a pivotal role in advancing this cause, particularly with relation to psychosocial intervention research. Findings of this content analysis indicated that the studies were most consistently published in medical journals (30 in pediatric and 29 in psychiatry journals) compared to 23 studies published in clinical psychology journals. Moreover, across all published studies, the median journal impact factor was relatively low (3.30) despite medical journals being overrepresented in our search, which tend to have higher impact factors. This pattern is concerning especially because evidence consistently shows that Black families prefer psychosocial interventions over pharmacological treatments for their children’s ADHD (e.g., dosReis et al., 2006), but the majority of treatment studies were published in medical journals and only four published in clinical psychology journals. Thus, editors, associate editors, and reviewers of impactful clinical psychology journals are uniquely positioned to draw the field’s attention to Black children with ADHD, and Black children’s mental health more broadly, by deliberately creating opportunities for and prioritizing publication of psychosocial treatment studies for Black youth. At the very least, editorial boards should require authors to report on the important demographic characteristics of study participants, including but not limited to race and ethnicity, while recognizing that the intentional investigation of racial/ethnic disparities extends beyond mere documentation of differences. Further, editors should acknowledge the early developmental stage of the body of literature on Black youth with ADHD, especially when evaluating studies with relatively small sample sizes. Just as in the early phases of ADHD research when it was acceptable for studies to focus on small numbers of White children, the same level of rigor should apply to early bodies of work on Black youth with ADHD, while encouraging contemporary study designs and analyses for smaller samples. Editors should remain aware of the evolving nature of this literature and communicate this point to reviewers as well. By collectively taking these steps, editorial boards can increase awareness of disparities and encourage the publication of studies that genuinely explore and address these issues. Through these measures, we can work toward closing the gaps in representation and promoting a more diverse and comprehensive understanding of ADHD in Black youth.
Limitations of the Present Study
The present study provides a wealth of content analysis following three seminal review articles on Black children with ADHD (Glasofer & Dingley, 2022; Miller et al., 2009; Samuel et al., 1997), though it is not without limitations. First, there is a possibility that we may have overlooked studies that meet the inclusion criteria. We mirrored search terms used in these previous reviews across two of the most prominent online databases (i.e., Psychinfo, PubMed) and thoroughly sifted through the references sections of several literature review papers, but we may not have captured the entirety of empirical studies on Black children with ADHD. Second, we only included studies conducted in the United States; thus, these critiques and suggestions for future research may not be generalizable to the African diaspora with ADHD outside of the U.S. Although structural racism and anti-Blackness are pervasive as they impact the health and mental health of Black youth across the world, some of this study’s conclusions and implications may be unique to clinical child psychology in the U.S. The last important limitation of this study is the failure to account for the diversity within the Black community in the U.S. including bi/multicultural families, immigrant families, and families with other intersecting identities. Although grouping all Black youth into a single racial category can yield valuable insights into ADHD-related racial disparities, it simultaneously impedes our ability to comprehend how distinct and intersecting factors encountered by Black Americans shape their experiences with ADHD. An increasing number of children identify as bi or multiracial in the U.S., and their nuanced experiences with race and racism are often ignored through this racial dichotomy. The vast majority of the existing literature assumes racial dichotomy and it would be beyond the scope of this paper to sufficiently capture the nuances of bi/multiracial youth’s experiences of having ADHD, but future research must acknowledge this diversification when considering the impacts of race and racism in psychological research. Likewise, future studies involving Black youth with ADHD should consider examining the impact of colorism—the preference for and privilege of lighter-skinned individuals with features closer to European standards over their darker-skinned counterparts (Adams et al., 2016; Monk, 2021). Colorism is often overlooked and underexplored, which is unfortunate given its established role as a determinant of social, economic, and psychological well-being among Black Americans (Bijou & Colen, 2022; Louie, 2020). It is possible that colorism may also play a role in the experiences of Black youth with ADHD and their families, and warrants further attention.
Conclusion
In the vast body of ADHD literature, Black youth’s experiences with ADHD have limited representation, which is not only limiting theoretical understanding of ADHD but also compromises culturally-sensitive, race-conscious mental healthcare for Black youth and families. This content analysis points to the need for more intentional and systematic investigation of the ways by which Black youth are diagnosed and treated for ADHD that holistically considers racially oppressive contexts as well as strengths that are protective for Black youth and families. Considering these critiques and suggestions for future ADHD research may be important first steps to promoting racial equity in mental healthcare for Black youth in the United States.
Supplemental Material
sj-docx-1-jad-10.1177_10870547241285244 – Supplemental material for ADHD in Black Youth: A Content Analysis of Empirical Research from 1972 to 2023
Supplemental material, sj-docx-1-jad-10.1177_10870547241285244 for ADHD in Black Youth: A Content Analysis of Empirical Research from 1972 to 2023 by Cathrin D. Green, Sungha Kang, Elizabeth A. Harvey and Heather A. Jones in Journal of Attention Disorders
Footnotes
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.
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