What is ADHD and How We Can Better Assess ADHD in Diverse Cultures?

Clinician Guidelines to Culturally Competent Care

Attention-Deficit/Hyperactivity Disorder is a highly prevalent and pervasive neurodevelopmental disorder. ADHD typically occurs in early development, prior to a child’s school enrollment and is characterized by persistent inattention and/or hyperactivity/impulsivity that affects an individual’s functioning and/or development. Individuals with ADHD can present with symptoms of inattention, hyperactivity/impulsivity, or a combination of both.

Inattention manifests behaviorally as failing to attend to details or making careless mistakes, wandering off task, lacking persistence, difficulty sustaining focus, and being disorganized. Individuals with inattentive features tend to reduce their engagement in tasks or activities that require sustained cognitive effort and may appear forgetful or distracted. Hyperactivity and impulsivity manifest behaviorally as excessive motor activity, restlessness or an inability to sit still when appropriate, appearing as if “driven by a motor”, difficulties waiting for one’s turn in social settings, social intrusiveness, and engagement in actions without recognition of the potential for harm or aversive consequences.

For a diagnosis of ADHD to be met, individuals must exhibit six or more symptoms of inattention or hyperactivity/impulsivity or a combination of both. Symptoms must be present for at least six months, are inconsistent with developmental norms, and directly interfere with an individual’s functioning. Symptoms must be present in at least two settings, such as at home, school, with peers/family, or during leisure activities.

ADHD is highly prevalent among youth and adult populations, with 11% of youth and 8.1% of adults affected during their lifetime. Recent research by London & Landes (2021) has demonstrated a significant increase in estimates of ADHD in adult populations by 24.6% in individuals aged 18-64 and a decrease in gender differences with respect to ADHD prevalence.

While estimates have shown higher rates of ADHD among men and boys, greater diagnostic clarity, symptom recognition, and systematic changes in health care have increased the assessment and recognition of ADHD symptoms in women and girls. However, disparities continue to exist for ADHD prevalence cross-culturally. These disparities in prevalence among diverse cultures may be due to cultural biases inherent in diagnostic assessment and clinical screening tools. Cultural prevalence rates may also differ, due to differences in the ways ADHD manifests in diverse cultures, interpretation of diverse youth behavior by clinicians or caregivers, and bias in rating and screening.

Despite research that demonstrates ADHD occurs in virtually all cultures and countries, the majority of the research on ADHD focuses on Caucasian Americans. However, race, culture, and ethnicity are critical to the assessment, diagnosis, and treatment of ADHD. While, searches for articles that include “ADHD” and “Race” have increased from 1990-2000, as well as reductions in bias in clinical care through diversity training that aim to reduce implicit bias, cultural biases in ADHD diagnosis continue. Furthermore, factors such as racism, stereotyping, trauma, and social disadvantage contribute to the maintenance or exacerbation of ADHD symptoms. These factors can also affect how an individual’s symptoms manifest, the likelihood an individual receives a diagnosis and treatment, and the rate of ADHD detection. Thus, recognizing how ADHD can present across various cultures is significant for clinicians and our communities.

For example, people of Hispanic heritage may be at risk for over-diagnosis, due to expectations within their culture to attend to and perform a variety of tasks during one period of time. This is in contrast to European American cultures who organize tasks and activities in a linear fashion, attending to a singular task or activity, prior to initiating another. Additionally, Hispanic culture deemphasizes structure, routine, and punctuality, whereas European Americans place a higher value on these factors. Therefore, Hispanic children may be at a higher risk of being perceived as impulsive and inattentive, symptomatic of ADHD, rather than behaving in accordance with their culture.

Because ADHD occurs during early, critical periods of an individual’s development, assessment and treatment of ADHD in all cultural groups is critical for the attainment of important skills required for a successful transition into adolescence and adulthood.

Tips for Clinicians in Providing Culturally Competent Care:

  1. Identify your own cultural biases and reduce them, through:
    1. Intellectual Engagement (learning about cultural groups through articles, videos, journals)
    2. Emotional Engagement (engaging in personal reflection with own biases, attitudes, and experiences with diverse groups)
    3. Relational Engagement (developing positive relationships with people from different cultural groups)
  2. Reflect on your life experiences with people of diverse cultural backgrounds
  3. Consider your own experiences of discrimination. Ask yourself: “Are there aspects of your identity that impact the way you perceive others?”
  4. Understand and assess key historical events, sociopolitical issues, basic values and beliefs, and cultural practices of your client.
  5. Consider cultural explanations in the diagnosis and conceptualization of mental health issues.
  6. Assess mental health through the use of a Cultural Formulation Interview*

Cultural Formulation Interviews in the diagnosis of mental disorders aims to identify and clarify key aspects of the presenting problem from the point of the individual and family members within the client’s social world.

A Cultural Formulation Interview:

  1. Elicits the individual’s view of core problems and key concerns
  2. Focuses on the individual’s way of understanding the problem
  3. Uses client language in the description of the problem
  4. Asks how the individual talks about their difficulties or symptoms with family and friends
  5. Focuses on the aspects of the problem that are most salient to the individual
  6. Obtains cultural perceptions of the cause of the problem, as well as factors that contribute to resiliency or the worsening of symptoms.
  7. Identifies the role of culture as a protective or promotive factor in healing and wellness.

While little research has been conducted on ADHD in diverse cultures, and racial/ethnic minorities are less likely to be assessed, diagnosed, and treated for ADHD, clinicians can mitigate these disparities in mental health care by utilizing a culturally informed approach to care with all clients.

Specialized Therapy Associates includes staff that is highly skilled in the assessment and treatment of a wide range of mental health issues.  For a free consultation with our intake coordinator who will match you to the best provider and service to fit your needs and goals, call 201-488-6678 or visit https://www.specializedtherapy.com/make-an-appointment/ to schedule an appointment.

 

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Centers for Disease Control (2020, November 16). Attention-Deficit/Hyperactivity Disorder  (ADHD). Data and Statistics About ADHD. https://www.cdc.gov/ncbddd/adhd/data.html

Conrad, P., & Potter, D. (2000). From hyperactive children to ADHD adults: Observations on the expansion of medical categories. Social Problems, 47(4), 559-582. https://doi.org/10.2307/3097135

Danielson, M. L., Bitsko, R. H., Ghandour, R. M., Holbrook, J. R., Kogan, M. D., & Blumberg, J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Null, 47(2), 199 212.         https://doi.org/10.1080/15374416.2017.1417860

Fletcher, J. M. (2014). The effects of childhood ADHD on adult lab market outcomes. Health

Economics, 23(2), 159-181. https://doi.org/https://doi.org/10.1002/hec.2907

Fletcher, J., & Wolfe, B. (2009). Long-term consequences of childhood ADHD on criminal activities. The journal of mental health policy and economics, 12(3), 119–138.

Evans, S. W., Owens, J. S., Wymbs, B. T., & Ray, A. R. (2018). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Null, 47(2), 157-198. https://doi.org/10.1080/15374416.2017.1390757

Hook, J.N., Davis, D., Owen, J., & DeBlaere, C. (2017). Cultural Humility: Engaging Diverse Identities in Therapy. Washington, D.C., USA: American Psychological Association. ISBN 1-4338-2779-4 (Digital, undefined format) or ISBN 978-1-4338-2779-2 (Digital, undefined format)

Iwamasa, G.Y. & Hays, P.A. (2019). Culturally Responsive Cognitive Behavior Therapy: Practice and Supervision (2nd edition). Washington, D.C., USA: American Psychological Association. ISBN 1-59147-360-8 (Hardcover)

Lensing, M. B., Zeiner, P., Sandvik, L., & Opjordsmoen, S. (2015). Psychopharmacological treatment of ADHD in adults aged 50+: An empirical study. Journal of attention disorders, 19(5), 380–389. https://doi.org/10.1177/1087054714527342

London, A. S. & Landes, S. D. (2021). Cohort change in the prevalence of ADHD among U.S.  adults: Evidence of a gender-specific historical period effect. Journal of attention disorders, 25(6), 771-781. https://doi.org/10.117/1087054719855689

Richards, P. S & Bergin, A. E. (Ed.). (2014). Handbook of Psychotherapy and Religious

Diversity (2nd edition). Washington, DC, US: American Psychological Association.

ISBN 1-4338-1736-5 (PDF) or ISBN 978-1-4338-1736-6 (PDF)