Part 1 of a special Psycom Pro series on the external factors that affect ADHD diagnoses and treatment outcomes – with Stephanie Mihalas, PhD, and Donna Y. Ford, PhD. Part 2 discusses how childhood trauma and parenteral stress can affect diagnosis and treatment decisions. Part 3 examines the impact of academic and social support in the lifespan of children and adults with ADHD.  See also, our clinical primer on the most accurate ADHD assessment tools.

Attention deficit hyperactivity disorder (ADHD) involves biological, environmental and genetic links – with an estimated genetic prevalence rate as high as 80% in families.1,2 Yet, while incidence rates have been increasing broadly in the US, there are wide variances in reporting, diagnosis, and treatment of ADHD among different racial and ethnic groups.3

There are documented disparities of both under and over-treatment in Black, Indigenous, and People of Color (BIPOC). Here, we dive into how sociocultural values and perspectives regarding ADHD may play a role.4

How Familial and Cultural Perceptions Impact the Acceptance of an ADHD Diagnosis

Studies show that race and culture impact perceptions regarding ADHD behavior symptomatology.5 These perceptions are significant because clinicians rely on subjective behavior ratings from educators, family, patients, and other caregivers to make their final assessments. Subjective behavioral interpretations can lead to bias in cumulative reports, which then open the door to affecting treatment courses and patient outcomes.4,6

In addition, when traditions, beliefs, and customs influence definitions of a particular illness, a patient’s or family’s tendency to seek help for the condition can wane.7 Their reaction and response to a condition such as ADHD can thereby add new barriers to already existing patient engagement and diagnosis challenges.8,9

For example, a study by Lawton and colleagues examined parental locus of control (PLOC) among Latino parents. They found two aspects of cultural values (fate/chance and parental efficacy) to be linked to beliefs that ADHD-related behavior would resolve on its own.10

According to Stephanie Mihalas, PhD, a nationally certified school psychologist, “Parents may feel their child’s behavior is unexceptional and a normal part of growing up, which can lead to conflicts when they are given school-based ADHD behavior referrals.” She explained that:

“The notion of ADHD varies extensively between cultures, religions, and ethnic backgrounds. It is not a fixed universal concept that practitioners can assume parents or even educators may buy into. Merely explaining DSM criteria will likely not impress upon various adults of children who are presenting with symptoms of ADHD that their child/student has this particular diagnosis, and even more so could create a barrier to treatment.”

Data show that cultural attitudes and sensitivities about ADHD can delay diagnosis, impact treatment rates, and affect use of stimulant medications. These beliefs differ around the globe among different racial and ethnic groups, including Asian, Middle Eastern, African, and those of South American descent.11,12

When Bias Affects Decisions around Behavior Ratings & Treatment

Culturally-grounded perspectives involved in decision-making include fear of stigma, negative attitudes about ADHD medications, disparate tolerance levels for child behaviors, and historic mistrust of healthcare providers among some BIPOC communities.13-15 A 2020 review by Slobodin and Masalha on sociocultural aspects of ADHD in minority children found cultural disparities led to undertreatment but conversely caused higher classification based on cultural, language, and racial bias.16

Research indicates that untreated childhood ADHD increases the long-term risks for substance use disorder (SUD), depression, and other comorbid behavioral health disorders. Undertreatment also has wider implications, including affecting families and individuals’ quality of life, health, and well-being later in life.17 (Psycom Pro will report on these effects in Parts 2 and 3 of this series.)

Undertreatment of ADHD may occur based on the four-stage ADHD Help Seeking Behavior Model (HSBM), developed by researchers to explain the potential rationale for disparities in diagnosis and treatment among minority children.18 The four stages include problem recognition, outreach for help, selection of services, and utilization of services.

While understanding cultural norms can assist clinicians to improve individual level patient-family interactions, it’s important to avoid stereotyping cultural perceptions of ADHD broadly. There are many variances among cultures and within families regarding ADHD.

 Paradoxically, studies have also shown that community-level factors, such as teacher bias in school-based subjective behavior ratings, may lead to disparities in ADHD referrals. A 2020 study by Kang et al showed that White teachers rated Black boys’ ADHD behavior levels and the probability of having ADHD greater than their parents.19 Subjective behavior assessments by teachers are inherently influenced by race, ethnicity, and culture of both teachers and students. (More on the accuracy of ADHD assessment tools.)

Diagnostic disparities can occur from educator over-reliance on subjective views or cultural stereotypes. These factors can contribute to bias in diagnosis referrals.20 Misunderstandings and behavior-based conflicts in school can also stem from gaps in cultural awareness due to disproportionate student-teacher racial/ethnic demographics. See Table I.

 

TABLE I: TEACHERS AND STUDENTS BROKEN DOWN BY RACE, BASED ON THE NATIONAL CENTER FOR EDUCATIONAL STATISTICS (NCES).21,22 

Teachers (2017-2018) Students (2017)
79% White 48% White
9% Hispanic 27% Hispanic
7% Black 15% Black
2% Asian 5% Asian
1% American Indian/Alaska Native 1% American Indian/Alaska Native

 

Research shows that Black students have higher rates of discipline referrals than other minority students, which has negative consequences on education and life outcomes.23 Bias, stereotypes, and discrimination in school can also lead to student disengagement and negative academic persistence.24 These traits are also often misidentified to be symptoms of ADHD, which in many cases, leads to the student not getting the proper classroom attention or accommodations they need.

Donna Y. Ford, PhD, a distinguished professor of education and human ecology at The Ohio State University, told Psycom Pro, “Educator bias and deficit-thinking can lead to cultural misunderstandings and contribute to mis-referrals. This affects Black males more often due to educator unfamiliarity with ‘vervistic’ or energetic movement in Black culture.”

According to Vanderbilt University’s IRIS Center, which is dedicated to improving education outcomes for all children, especially those with disabilities, through evidence-based interventions, cultural variations in behavior can impact personal reactions and interactions with others.25

Cultural differences include:

  • directness – some cultures value direct approaches to topics of concern while others prefer a more gradual approach to sensitive discussions
  • emotional context – the degree of outward emotional displays including tone of voice and facial expressions differs among cultures and may be misinterpreted in a negative manner
  • communication – physical movements, gestures, personal space, and levels of verbal engagement in discourse all differ among cultures
  • reaction to authority figures – in some cultures, making eye contact while communicating with authority figures is viewed unfavorably or as being disrespectful (eg, respeto in Latino cultures26)

 In school-based student-parent interactions, Dr. Mihalas noted, “What is of critical importance is explaining some of the particular concerns that the student/patient is having in the environment in question and how you, as a professional, may be able to help.”

She added, “If a student may be fidgeting excessively and this is impacting how other peers are able to relate to the student, explain this openly and honestly. Many parents would want their child to connect with other peers. However, if you talk about the abnormal nature of movement, some cultures may disagree with this, and immediately the line in the sand is drawn. If a clinician is not aware of the cultural interpretation of ADHD, and the model of the family’s culture is not matched appropriately, the likelihood of getting support to the family will be pushed to the wayside.”

Improving ADHD Outcomes:  How to Apply a Culturally Sensitive, Collaborative Approach

In addition to impacting assessment attitudes and beliefs, culture, race, and ethnicity can also have important implications in ADHD treatment.27 Given the outlined disparities, what is the best course of action for clinicians?

For some, it begins in the research arena. Several groups, including Native Americans, Arab Americans, and Asian communities, are underrepresented in studies regarding cultural influences on ADHD. This lack of data adds another dimension to the challenge of understanding divergences in diagnosis and treatment.

For daily practitioners, BIPOC patients may face challenges navigating the healthcare system due to the lack of culturally relevant treatment options. Again, such challenges are largely unknown due to the dearth of research studies among underrepresented groups – but asking the right questions of patients and caregivers can help address this issue.

Other key components of culturally competent care include assessing:

  • the presence and degree of language barriers (use community cultural navigators)
  • educational level and health literacy level
  • role of family and community in healthcare decisions
  • attitudes about medications for ADHD

Dr. Ford also recommends increasing school-based professional development to boost cultural awareness. She suggests using neutral assessments, increasing self-reflection “while getting out of your comfort zone to address bias and racism,” and improving multicultural education. Dr. Ford also advises that clinicians making assessments gather information “from multiple sources to avoid subjective bias from reporting sources” – sources could include caregivers, educators, and counselors.

Behavioral health professionals often use objective measures, such as clinical interviews, cognitive tests, and symptom validity tests in ADHD diagnosis. These can work to reduce rater bias from subjective perceptions, including from socio-cultural influences on both the child and the clinician.28,29 Use of multi-informant assessments for subjective behavior ratings is also significant for the individual patient and family in demonstrating trust and developing shared strategies.

Overall, ADHD is a complex condition with multifactorial familial and clinician influences that can too easily affect diagnosis and treatment outreach. The significance of ethnocultural context that leads to disparities in treatment cannot be understated. Cultural relevance training among clinicians and mental health professionals to reduce implicit bias and increase understanding is crucial to bridging these gaps.30

Read Part 2 of this series on how adverse childhood experiences affect ADHD and Part 3 on the long-term impact of ADHD into adulthood. Plus, stimulants and when misuse comes into play.

Related articles

How to track progress in students with ADHD during COVID remote learning and why to ask about sleep issues

Remote Learning in ADHD StudentsThe Insomnia LinkDoes CBD Work for ADHD?ADHD Assessment Tools to Use
References
Last Updated: Jun 16, 2021