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Chapter 2: Literature Review


Every research requires a comprehensive and continuing review of the literature that is relevant to the topic of study. The ongoing nature of the review is particularly essential in the current research since a great deal continues to be written regarding Attention Deficit Hyperactivity Disorder’s (ADHD) “evolving concept”. It is possible to devise theoretical and analytical framework using various sources.

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They can also assist in the identification of key issues and the provision of ideas for the classification and presentation of data (Bell, 1999). Numerous suggestions regarding the definition and the format of the literature review (Phillips & Pugh, 2010; Bell, 1999; Arthur, Waring, Coe & Hedges, 2012; Barton, 2006). Ayiro (2012) states that researchers utilize the scholarly literature in studies in order to present findings of similar studies. Ayiro (2012) also adds that such literature is used in making comparisons between the study and the ongoing dialogue, and also to provide a framework for the comparison of findings of the study with other studies.

The literature review will focus on the research questions and highlight what other authors and researchers suggest. The research questions focus on various areas including whether there is a significant difference in behavioral problems among the African-American, Hispanic, and Caucasian children with ADHD in the custody of Children Protective Services (CPS). It also focuses on learning various issues involving these children, including the ratio of boys to girls diagnosed with ADHD and the disparity in diagnosis among the different races.

Another feature will be on research related to the differences in school attendance based on these ethnicities. Academic performance and other issues related to the education of the children with AHDH will also be analyzed, including the standardized school testing scores for the different ethnicities of children with ADHD. In addition, the study will focus on the legislative and legal issues regarding ADHD in the USA.

In addition, it will assess the available literature on symptoms, diagnosis, and medications. This research involves the study of the children suffering from ADHD, who are under the custody of children protective services. It also focuses on learning various issues involving these children, including the ratio of boys to girls diagnosed with ADHD and the disparity in diagnosis among the different races. Various authors have conducted research and documented their findings involving these issues. The literature review will explore the literature related to all aspects of ADHD among children.

Another section focuses on the interrelationship between theory and ADHD. The theory is examined on various levels including the abstract concept of ADHD, its manifestations in daily life, and assessment procedures. Identifications of key issues for study and areas that need further research are made throughout the chapter. The details are utilized in the substantiation of research questions, areas of investigation, and hypothesis in the current study.

Search Strategy

The topic under review has numerous aspects; hence, it required diversity in the literature reviewed. The literature reviewed includes internet sources, journal articles, and books. Various online search engines were used to gather the relevant articles and books including Google Scholar, Google Books, PubMed, PsycINFO, JSTOR, and Pubmed. Key terms used in the searches include Attention Deficient Hyperactivity Disorder, ADHD, Ethnicity, and ADHD, Culture and ADHD, ADHD interventions, ADHD Professional Perspectives, among others.

The different searches provided numerous results, but only 40 of the relevant results were used in the study. The sources used are dated from 1998 to 2014. It proved important to use some of the older articles and books in order to gather the historical background of the study, and also gain an understanding of the evolution that has taken place prior to conducting the current study. Since some of the books were not available as hard copies on the Internet, it was necessary to visit a physical library and search for them. The literature reviewed originated from various parts of the world, but particularly the USA and Britain.

The entire process of searching the literature and using it in the literature review required consistency and planning. Some of the literature contained helpful information that could be used in different sections of the literature review. Therefore, there was the recording of the topics that are handled by the given article or book and their relevance in the current study. In addition, filters were used to limit the search results. For instance, in most cases, older articles or books contain outdated information. Therefore, if the search results produced an older book, a search for a newer edition of the book would follow. Except for where the information needed provided historical context, all articles had to be recent.

Legislative Framework

Research on issues related to special education requires a search on the legal concept of inclusive education. Legislation has focused on various aspects of education in relation to disability and special needs. Students who have ADHD are unable to cope with the ordinary system of education. As a result, they need to be in classes that focus on their particular needs, or they have to use the special curriculum.

However, they cannot be prevented from acquiring an education based on their disabilities. It requires multidisciplinary approaches when identifying and managing ADHD, and classroom practices whose curriculum is flexible to meet the needs of the children with ADHD. In 1994, the World Conference on Special Needs Education drafted the Salamanca Statement. It endorsed the need for inclusivity in education. It requires that a school curriculum should be flexible and adaptable to children with special needs (Cooper & Bilton, 2002).

Its purpose was to broaden the access to education for all people, regardless of their disabilities. Inclusive practices have been researched, with numerous researchers offering appropriate ways of doing it. The majority of the developed countries have schools with a mix of special and mainstream classes (DuPaul & Stoner, 2014).

ADHD: Theoretical Concept

Definition and Diagnosis

Although there is a massive volume of literature on ADHD, its precise definition is still debatable (Jackson, 2013). Alban-Metcalfe and Alban-Metcalfe (2012) state that the majority of the authors agree that ADHD is a medical disorder. Bailey et al. (2010) define it as a neurobehavioral development disorder, while McBurnett and Pfiffner (2008) define it as a medical diagnosis of a behavioral condition.

According to Kewley (2011), it is a complex neurodevelopmental constellation of problems and not a single disorder. Ryan, Katsiyannis, and Hughes (2011) define it as a neurological condition that is driven by the environment. Often, there is a polarization of professional opinions, which leads to disagreements between the educationalists and psychologists. This can be seen when discussing the best course to follow when treating the disorder (Langwith, 2009).

The condition of ADHD revolves around three core characteristics: inattention, hyperactivity, and impulsivity. Inattention is seen in various behaviors, especially when an individual ignores the teacher and fails to complete tasks). When there is excessive impulsivity, the child speaks, exhibits excessive emotional reactions, or acts without thinking (Ryan, Katsiyannis & Hughes, 2011).

Hyperactivity entails developmentally inappropriate or excessive activity levels, whether vocal or motor (Bailey et al., 2010). Such movements, which are often seen as irrelevant to the task, include excessive toe-tapping and knee jiggling (Bailey et al., 2010). Inattention can be observed when a child does not respond to questions or instructions. When diagnosing ADHD, it is important to ensure that all the features are manifested on numerous occasions (Ryan, Katsiyannis, & Hughes, 2011).

Controversy exists on the conceptualization of ADHD, with numerous research to unify the themes being conducted. As a result, there is diversity in the theoretical accounts of ADHD (Kewley, 2011). DuPaul and Stoner (2014) suggest that there is a struggle in the environment that requires goal-directed action, demand restraint, self-regulation, and delayed gratification, which children with ADHD cannot meet. It is vital to ensure that the changes in nomenclature are observed in order to reflect the dynamic conceptualizations of the disorder’s nature (Cooper, 1999).

Cooper and Bilton (2002) focus on the lack of inhibitory control as the underlying problem instead of attention deficiency. Barkely (2005) generates a theory that focuses on ADHD through three aspects of inhibition of behavior: pre-potent response, ongoing responses, and responses to task-relevant events. Barkely (2005) elaborates the impact of the inhibition in behavior through four executive functions, which include verbal working memory, non-verbal working memory, reconstitution, and self-regulation of motivation. Various authors and researchers have discussed the impact of ADHD on executive function. However, each impact results from the particular subtype involved (Westby & Watson, 2004).

History and Changes in Terminology

In an 1846 children’s book titled Struwwelpeter, a German physician, Heinrich Hoffman, including a story that described symptoms associated with ADHD (Butcher, Mineka & Hooley, 2013). A detailed discussion about ADHD took place in 1902 when a British pediatrician, George Still, reported on children who behaved in a manner characterized by a predisposition to be deviant. They also lacked inhibitory volition, vindictiveness, and fervent ness. He hypothesized that the cause could be mild brain injury (Butcher, Mineka & Hooley, 2013). In the 1930s, brain injury was thought to cause most of the behavioral disturbances, and amphetamine was used in 1937 for the treatment of children with behavioral disorders.

Butcher, Mineka, and Hooley (2013) state that the term “Minimal Brain Dysfunction” was first used in the 1950s and 1960s and that the disorder was no longer attributed to brain damage. The focus of a possible cause was brain mechanisms. In 1957 physicians began using Methylphenidate, and the symptoms of the disorder included hyperactivity. It led to the medical term “hyperactive child syndrome” (Stahl & Mignon, 2009). However, Stahl & Mignon (2009) add that research in the 1970s revolved more around attention rather than hyperactivity, and the condition Attention Deficit Disorder (ADD) was established. It was published in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), by the American Psychiatric Association (APA) in 1980. The term ADHD was first used in 1987 and was redefined in 1994 (Stahl & Mignon, 2009).


The available literature indicates consensus regarding the absence of a single cause of ADHD. In addition, the exact cause of ADHD is unknown. However, numerous authors and researchers offer varied theories about the source of the disorder. A widely accepted perception focuses on the medical model that posits that ADHD results from genetics, and neurological abnormalities or brain injuries (Ryan, Katsiyannis & Hughes, 2011). The principal cause is believed to be a neurological dysfunction (Brassett-Harknett & Butler, 2007; Egger, Kondo & Angold, 2006).

Research on ADHD has found that there are low levels of activity in the neurotransmitters of the brain’s frontal lobes, which are responsible for controlling impulses and regulating attention. Egger, Kondo, and Angold (2006), state that the behavior of children with ADHD could be a result of structural anomalies in the brain’s prefrontal cortex. It could also result from abnormalities in the prefrontal cortex. Cooper and Bilton (2002) state that the causes of this particular brain dysfunction appear to be genetic, with 70 percent of the cases being inherited. The remaining 20-30 percent can be attributed to environmental factors including exposure to toxins, brain injury, and brain disease.

Biederman and Faraone (2005) suggest that risk factors associated with ADHD include pregnancy complications and those associated with childbirth, low birth weight relating to prematurity, and exposure of the fetus to tobacco and alcohol. Babies born to alcoholic mothers risk having Fetal Alcohol Syndrome, which is one of the hallmark symptoms of ADHD. Medina (2011) suggests that since the amount of alcohol that causes the syndrome is unknown, pregnant mothers should avoid alcohol altogether.

Children who watch television and playing video games for a long time may result in ADHD or increase the behaviors associated with ADHD (Medina, 2011). When parents allow their children to watch television for long periods, they contribute to their inattentive behaviors. The socio-cultural misunderstandings relating to ADHD revolve around the fact that different cultures have varied standards for their acceptable and unacceptable behavior (Medina, 2011).

Other researchers believe that the dysfunction lies in other parts of the brain, which include the cerebellum, basal ganglia, anterior cortical regions, and striatal regions of the cortex (Munden & Arcelus, 1999). However, there is no consensus about this. Other scientists suggest that there is a biological cause, which links an individual’s ability to pay close attention to detail, and the individual’s level of brain activity.

The level of glucose used by the brain areas, which inhibit impulses and control attention, has an impact as well (Langwith, 2009). McGough (2014) states that brain injury could cause ADHD. A child with certain brain injuries exhibits similar symptoms to that of a child with ADHD. McGough (2014) also observes that in the early days, ADHD was referred to as minimal brain dysfunction. Only a small percentage of children with ADHD have suffered injuries in their brains. As a result, there is a lack of sufficient evidence that points to the brain injuries as being a possible cause of ADHD (Jackson, 2013).

Studies suggest that there is a link between genetics and ADHD (Butcher, Mineka & Hooley, 2013). For example, research shows that about twenty-five percent of close relatives in a family with ADHD also suffer from the disorder (Cooper & Bilton, 2002). In fact, the majority of the children with ADHD have a close relative who, to some degree, is also affected by ADHD.

Kewley (2011) found that among identical twins, when one of them has ADHD, 90 percent of the time the other twin has it as well. Among regular siblings, when one of them has the condition there is a 30 to 40 percent probability that other siblings will have it too. Munden and Arcelus (1999) explain the multiple causes of ADHD with reference to nature and nurture. This means that it is a problem with a living element, but one that interacts with psychosocial factors in an individual’s social, social, and physical environment (Munden & Arcelus, 1999).

The biological factors include brain functions and genetic influences. The psychological factors include emotional and cognitive processes, while the social factors include the child-rearing practices of the parents and classroom management (Munden & Arcelus, 1999). Genetics in relation to ADHD shows that the disorder is present in the family line. Research shows that about twenty-five percent of close relatives in a family with ADHD also suffer from the disorder (Cooper & Bilton, 2002). Studies suggest that there is a link between genetics and ADHD (Butcher, Mineka & Hooley, 2013).

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However, Brassett-Harknett and Butler (2007) observe that ADHD is not just a medical condition, but is also a disorder that is influenced by the environment. The environmental situation offers a perspective for an individual with ADHD to understand and get treated. In order to minimize distress emanating from the disorder, it is essential to have an appropriate “fit” between an individual and the environment. Numerous factors are in the environmental classification including culture, family, and society (Brassett-Harknett & Butler, 2007). Brassett-Harknett and Butler (2007) include food additives and sugar, lead, substance abuse during pregnancy, and high levels of television viewing. Howard et al. (2011) conclude that food additives and sugar intake increase the levels of hyperactivity in children. However, other studies do not support the findings.


Statistics show different figures from different research related to the incidence of ADHD. It can be attributed to the diagnostic standards applied and the place and time when the study was conducted. ADHD is also a worldwide problem. According to Cooper (1999), the prevalence of ADHD is between 3 percent and 6 percent throughout the world. Chamberlain and Sahakian (2006) estimate that the prevalence is between 4 percent and 10 percent, while Biederman and Faraone (2005), suggest that it is between 8 percent and 12 percent. Holland and Riley (2014) offer more recent statistics on the prevalence of ADHD. Males are three times more likely to be diagnosed with ADHD than females.

The difference is about 12.9 percent among males to 4.9 percent among females. They state that about 5 percent of children in the world have ADHD. In the United States, 11 percent of children between four and seven years have this condition. The APA (2013) states that the prevalence of ADHD in children between 4 and 17 years increased from 4.8 percent and 6.1 percent between 2007 and 2011.

The estimates of the gender variation in prevalence vary with more boys than girls (Biederman & Faraone, 2005) having ADHD. The male to female ratios ranges from 4:1 to 9:1 depending on the setting. The general population has lower statistics than what is available in health facilities (American Psychiatrist Association, 2013). The occurrence approximations depend on the ADHD subtype used in a study.

In the hyperactive-impulsive type, the ratio between boys and girls is 4:1. The ratio for hyperactivity is estimated to be 1:2 (American Psychiatrist Association, 2013). ADHD occurs across cultural and social boundaries, and in all ethnic groups (Chamberlain & Sahakian, 2006). In addition, it cannot be attributed to certain cultural practices. However, reporting about the disorder is lower among the children in lower social classes (Holland & Riley, 2014).

Comorbidity and Associated Problems

McGough (2014) defines comorbidity as the simultaneous existence of two or more varying conditions or disorders. Studies suggest that around 60 percent to 70 percent of children suffering from ADHD also have co-existing conditions. The co-existing conditions add complications to what a child with ADHD experiences (McGough, 2014). These conditions and disorders may include conduct disorder (CD) and oppositional defiant disorder (ODD); speech and language disorders, dyslexia, learning difficulties, dyscalculia, dyspraxia. They may also include Tourette’s syndrome, tics and obsessive-compulsive disorder (OCD); depression, and anxiety (McGough, 2014; Chamberlain & Sahakian, 2006; Butcher, Mineka & Hooley, 2013).

Cooper and Bilton (2002) suggest that poor self-esteem is common among children diagnosed with ADHD. As a result of this combination, the children begin underperforming socially and academically. These children also suffer from handwriting and fine motor control difficulties and sleep difficulties. They also find it difficult to self-regulate their emotions, manage time, and other organizational problems (Kewley, 2011). They may also be oversensitive and may not be able to maintain relationships (Cooper & Bilton, 2002).


Kewley (2011) states that there is the assumption among many that when a child reaches puberty, ADHD disappears. In addition, they think that the children with the condition will also outgrow their behavioral difficulties once they reached early adulthood. Studies had shown that between 70 percent and 80 percent of children with ADHD continue exhibiting symptoms even when they reach adolescence and early adulthood. However, the symptoms may differ due to the maturation and cognitive development associated with young adulthood (Kewley, 2011).

It is essential for the children to receive individualized treatment due to the differing characteristics expressed by the adolescents. Cooper and Bilton (2002) state that between 30 percent and 70 percent of the children with ADHD retain the characteristics even during adulthood. Chamberlain and Sahakian (2006) suggest that half of the children with ADHD retain the characteristics into adulthood.

McCormick (2004) conducted a study investigating the outcome of child and adolescent ADHD during adulthood. Seventy-three individuals participated in the study, and the results showed that only 4 of the participants retained ADHD during adulthood, which is 5.5 percent of the participants. The majority of the people who continue exhibiting ADHD symptoms during adulthood do not meet the diagnostic criteria outlined in DSM. There is usually a decline in the intensity and frequency of their symptoms. The impulsive behavior lessens, but there may be persistence in organizational and learning problems (Cooper & Bilton, 2002).

Chamberlain and Sahakian (2006) state that it is believed that pediatricians identified adulthood ADHD when they noticed that parents of children with ADHD had similar symptoms to their children. These adults may suffer from self-destructive and antisocial behaviors. They also face difficulties when dealing with social and emotional problems, criminality, substance abuse, and unemployment (Chamberlain & Sahakian, 2006).


Often, it is a challenge to resolve the most effective interventions for each individual pupil with ADHD due to the variability of their response to treatment, and the heterogeneity in symptoms and characteristics displayed. Various types of interventions are used in the treatment of pupils with ADHD, who may have difficulties in the affective and cognitive domains.

Medical Interventions

DuPaul and Stoner (2014) indicate that stimulant medications have been found to have a positive impact on attention span, social relationships, academic performance, and impulse control. The aim of the drugs is to control the symptoms so that a child becomes more receptive to other forms of non-medical interventions through affecting the balance of dopamine and noradrenaline in the brain. Cooper and Bilton (2002) suggest that medication alone is not sufficient in treating and extinguishing undesirable behavior in children with ADHD.

However, it offers a window of opportunity for the child to benefit from teaching and learning experiences that teachers, parents, and others provide. DuPaul and Stoner (2014) state that physicians prescribe psychostimulant medications such as methylphenidate (Ritalin), mixed amphetamine (Adderall), and dexamphetamine (Dexedrine) to children with ADHD as a way to increase the arousal of the central nervous system (CNS). In addition, Pemoline (Cylert) can be used, but its use is less frequent as a result of concerns associated with failure of the liver (Cooper & Bilton, 2002).

The original forms of psychostimulants are taken time to take effect and are administered two to three times daily. Since sustained release versions of dexamphetamine and methylphenidate are now available, they are becoming the preferred treatment option for children suffering from ADHD (DuPaul & Stoner, 2014). The use of other types of medication has also succeeded in the treatment of ADHD including tricyclic antidepressant medications such as desipramine and imipramine (Cooper & Bilton, 2002).

In addition, non-stimulant medications including atomoxetine (Strattera), clonidine (Catapres), and bupropion (Wellbutrin) can be used for treating the disorder. Ninety percent of children diagnosed with ADHD in the USA receive medical therapy. The majority of these children, about 1.5 million or 4% of the school-going population receive treatment through psychostimulant medications.

On average, such medication is used for a period between two and seven years (Cooper & Bilton, 2002). It is of paramount significance that the right dosage of medication is prescribed and that there is the regular follow-up to monitor the timing and dosage. In addition, the side effects must also be considered (Cooper & Bilton, 2002). DuPaul and Stoner (2014) state that it is crucial to have effective cooperation between the health and education professionals. This assists during the monitoring of the negative and positive effects of the medication.

Educational Interventions

Classroom interventions. The majority of the environmental, classroom management, and educational interventions already in place in some schools may be appropriate for the pupils with ADHD in different ways. Numerous classroom strategies to be used by children with ADHD have been offered (Kewley, 2011). Saul (2014) suggests three broad features that are critical in working with children with ADHD: structure or routine, variety, and brevity. It has been suggested that physical activity increases dopamine levels in the brain; hence, having a similar impact to that achieved through taking stimulant medications (Saul, 2014).

A study conducted by Medcalf, Marshall, and Rhoden (2006) showed that the “on-task” behavior of pupils with emotional behavioral disability (EBD) in a mainstream secondary school demonstrated improvement following physical education lessons. The inclusion of periods of structured physical activity at regular intervals throughout the school day could produce positive outcomes for pupils with ADHD (Jackson, 2013).

There is also the use of nurture groups in mainstream schools as an early intervention for children suffering from emotional and social difficulties (Jackson, 2013). Some children with ADHD benefit from this type of setting, which combines the features of a caring, home-like environment and those of a standard classroom. The emphasis is on emotionally supportive and emphatic relationships between the children and the adults (Cooper & Bilton, 2002). Cooper and Bilton (2002) also add that there is a predictable daily routine, which comprises of intensive interaction, periods of structured physical activity, recess periods, and a holistic curriculum.

Typically, a nurture group consists of ten to twelve pupils, a teacher, and a teaching assistant. The pupils remain in the system of a mainstream class, and they spend curriculum time in this class when they are not attending the nurture group. They are reintegrated full-time into the mainstream classes after a period of two to four terms (Jackson, 2013). Research on the effectiveness of the nurture groups is limited, but Cooper and Tiknaz (2005) discuss the opportunity to gain and opportunity cost, and also communication between mainstream and nurture group staff. Some of the findings reveal that the children benefit from the system, but the behavioral gain transfers less effectively to mainstream settings (Cooper & Bilton, 2002).

Social Interventions

Children with ADHD find it difficult to socialize, initiate and maintain friendships. They seem to be oblivious of the manner in which their behavior affects other people around them. Among other problems, they suffer from social ineptness or social clumsiness (Kewley, 2011). For instance, children with ADHD may try to join in a game without asking for permission. They fail to observe the rules of proper conversation and are likely to interrupt others. They are also more likely than their non-ADHD peers to express aggression. As a result, they may experience rejection and isolation from their peers (DuPaul & Stoner, 2014). It is important that children with ADHD be taught basic social interaction skills. It may be done in school, at home, or through voluntary agencies such as guide leaders, football coaches among others who understand the nature and concept of ADHD.

Anshtel (2005) suggests that there ought to be preschool training in social skills for the pupils with ADHD alongside the non-ADHD pupils with the goal of fostering their social functioning at an early age. It is important that they have an effective curriculum that focuses on the unique problems that they face. It is also important that the skills of self-advocacy be improved (Cooper & Bilton, 2002). They also stress the importance of the children with ADHD not feeling guilty or ashamed for their concentration lapses. They should have the confidence to approach a teacher and ask them to repeat a point that they may have missed (Cooper & Bilton, 2002).

Complimentary or Alternative Interventions

Sinha and Efron (2005) state that children with ADHD also receive complementary and alternative medications, but the effectiveness of this treatment strategy varies. In addition, many of the interventions are controversial as they have no established or minimal efficacy for ADHD children, and they lack ample research evidence (DuPaul & Stoner, 2014). Fish oil supplements have been used for children suffering from developmental coordination disorder (Richardson & Montgomery, 2005). The findings suggest that there is an improvement in behavior, writing, and writing after three months. Other treatments employed include multivitamins and zinc, herbal and natural medicines, brain gym, amino acid supplementation, diet, yoga, tinted lenses, and development optometry among others (Cooper & Bilton, 2002; Sinha & Efron, 2005; DuPaul & Stoner, 2014).

Current Theoretical Concerns – ADHD

Since the redefinition of ADHD in 1994 in DSM-IV, numerous theoretical aspects relating to ADHD have risen. Some of the controversies and debates relate to symptoms, prevalence, etiology, consequences, treatment, longevity, and constituency (Tait, 2005). Various issues contribute to the difficulties experienced in the provision of appropriate behavioral and learning support in inclusive education for children with ADHD.

A fundamental discussion revolves around the existence of the disorder (Biederman & Faraone, 2005; Kewley, 2011). Some critics have questioned whether ADHD even exists as a legitimate diagnosis. They insist that the children labeled as having ADHD are normal children whose parents and teachers cannot tolerate behavioral variations (Westby & Watson, 2004). Cooper and Bilton (2002) develop a summary of some of the grounds raised by the people either “for” or “against” the ADHD concept. The people opposed to the concept offer the following arguments:

  1. It is an American craze or scientifically uncertain concept
  2. It is an effort to hide the real causes of psychosocial conditions
  3. It is an excuse for ineffective schools and poor parenting
  4. It is an excuse to overpower and control the natural enthusiasm and extemporaneity of independent and creative children using powerful medication.

The people supporting the existence of ADHD offer some of these arguments:

  1. It is an explanation of all the aspects of a person’s educational, social and professional failure
  2. It is an indicator of superior attributes that render the bearer a member of a given group
  3. It is conclusive proof of the inaccuracy of environmental explanations for school failure and behavioral problems.

The majority of the disciplines accept the existence of ADHD. In fact, it has been endorsed by various researchers and professionals (Tait, 2005; Timimi, 2005; Barkley, 2005; Cooper & Bilton, 2002; Sinha & Efron, 2005; DuPaul & Stoner, 2014). Different perspectives exist in regard to the definitions of features of the disorder and the core symptoms. Barkley (2005) incorporates the concept of multidimensional construct including selectivity, arousal, alertness, distractibility, and span of apprehension.

DuPaul and Stoner (2014) identify three variations of attention control, which include attention switching, selective attention, and vigilant attention. Kewley (2011) includes impulsive control and divides it into verbal, emotional, and physical impulsiveness. Kewley (2011) also suggests that the condition may be under-diagnosed, or undertreated. Timimi (2005) suggests that it may be over-diagnosed.

Multi-Professional Identification and Assessment

Various concerning regarding identification and assessment procedures of ADHD exist. A precise valuation of ADHD necessitates proof of the pervasiveness, and it ought to be based on detailed information from teachers, parents, and school psychologists in conjunction with other professionals (Cooper & Bilton, 2002). Multimodal or multidisciplinary approaches to the identification and treatment of ADHD are considered to be essential (DuPaul & Stoner, 2014).

Professional judgment is also very important due to the lack of the unerring standard for the diagnosis of ADHD. Improved communication between disciplines is also necessary. In addition, there should be clear guidance relating to diagnostic and treatment processes (McGough, 2014). It is especially vital to have effective cooperation between the health and educational professionals when there is the use of medication as part of a multi-modal intervention (Cooper & Bilton, 2002). Cooper & Bilton (2002) discuss the use of ICD-10 for hyperkinetic disorder and DSM-IV for ADHD.

The main variance between ICD-10 and DSM-IV is that ICD-10 focuses on hyperactivity and does not have a non-hyperactive subtype. During the ADHD assessment process, numerous rating scales have been used. They use the frequency of behavior outlined in the DSM-IV, for hyperactivity, impulsivity, and inattention. The use of labels or diagnostic classifications also raises controversies. It is vital to have common classifications used by the educational, health, and legal professionals relating to ADHD (DuPaul & Stoner, 2014).

One of the most contentious matters concerning ADHD is the use of medication. Most of the parties supporting the use of medication advocate it as part of a multi-modal approach to treatment (Cooper & Bilton, 2002). The method has been demonstrated to be effective in the decline of the main symptoms of ADHD (DuPaul & Stoner, 2014). Reports show that there is an improvement in attention, behavior, and concentration among children with ADHD, but the results on its impact on academic performance are conflicting. Such children express improvement in relating with their family members and friends (Ryan, Katsiyannis & Hughes, 2011).

The people against the use of medication on the treatment of ADHD cite the side-effects of the medication, which include abdominal pain, appetite suppression, sleep difficulties, itchy skin, depression, and mood variations among others (Ryan, Katsiyannis & Hughes, 2011; Cooper & Bilton, 2002; DuPaul & Stoner, 2014). Some of the long-term side-effects include weight gain and the stunting of height (Cooper & Bilton, 2002). The use of medication also poses a threat to drug addiction and abuse. However, the evidence is not available on the addiction to stimulants used in the ADHD treatment (Bierderman & Faraone, 2005).


Even though research on ADHD exists, most of the studies have been conducted on white, male, middle-class subjects (Butcher, Mineka & Hooley, 2013). Researchers have overlooked the diversity variables during the diagnosis and treatment of children with ADHD. For instance, there is cultural variation about the behaviors that might be more prevalent in one culture, and they may not be as common in another culture. Inagaki (2011) found that African-American children had the highest rates of ADHD while Asian-Americans had the lowest. Hispanics and Caucasians had the average.

African-American children have also been found to have higher rates of hyperactivity than Caucasians. Miller, Nigg, and Miller (2009) conducted a study whose results showed that two-thirds more African-American children were diagnosed with ADHD than Caucasians. However, it is imprecise as to whether the variations are due to the actual racial differences, rater bias due to ethnicity or it is a combination of the two (Bailey, 2010). Zwirs et al. (2011) state that there could be a bias with the teachers reporting the disorder. Caucasian teachers’ rating of an African-American student’s higher than the white students. On average, African American teachers rated the African-American students lower. The biases contribute to the overrepresentation of African-American children in special education classes (Butcher, Mineka & Hooley, 2013).

There are important cultural variations in the demands of the environment at school, home, and communities of different cultural and ethnic groups. In regard to the socioeconomic status, poor rural areas have higher rates of ADHD compared to urban areas (Butcher, Mineka & Hooley, 2013). In addition, cultural variations exist in relation to beliefs and attitudes relating to illnesses, choice of care, degree of towards institutions and authority, access to care, and tolerance for particular behaviors. Failure to have ADHD diagnosed earlier in life may be pegged to ethnic values, practices, and beliefs. Culturally specific beliefs and health behavior can be an explanation of the significant amount of care-seeking and adherence patterns.

However, less is known as to whether and the manner in which ethnicity influences health perceptions and practices regarding ADHD (Bussing et al., 1998). Cultural differences on the part of the teacher perceptions, parent perceptions, and socioeconomic status play a role in the determination of a child’s hyperactivity. Saul (2014) states that using parent report fewer Hispanics and African-American children were likely to be diagnosed with ADHD as compared to white children. Low socioeconomic status may lead to hyperactivity.

This can occur if the children are subjected to psychological or environmental stressors. As a result, children from families with lower socioeconomic status may have a higher hyperactive diagnosis than those with higher socioeconomic status (Butcher, Mineka & Hooley, 2013). There is also a possibility that the variation in the diagnosis of ADHD in different ethnicities is based on economic differences (Saul, 2014).


After a brief introduction, the literature review analyzed the theoretical concepts of ADHD. These include the definitions, diagnosis, history, and changes in terminologies, etiology, prevalence, comorbidity, and other associated problems. The theoretical concepts discussed by different authors and researchers provided a background on the present research. The section on ethnicity also played a role in setting the background and understanding the perspectives of different authors in relation to ADHD. Throughout the literature review, there were three main levels.

  1. The first level was related to professional perspectives. It expresses their views on various issues discussed.
  2. The second level focused on the disorder’s manifestations. The focus is more on the school context and school-going children.
  3. The third level focused on multi-professional procedures applied in the identification, valuation, and management of ADHD. It is evident that various authors and researchers have different perceptions on issues relating to ADHD.

There is a gap in the factors that result in a variety of diagnoses among the different ethnicities. It is unclear as to whether it is the result of cultural, economic, or ethnic impacts. Therefore, the current study will also aim at filling that gap in the literature.

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