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CME Commentary

Culturally Competent Strategies for Assessing and Treating ADHD in African American Adults

 

CME Background

Articles are selected for credit designation based on an assessment of the educational needs of CME participants, with the purpose of providing readers with a curriculum of CME articles on a variety of topics throughout each volume. Activities are planned using a process that links identified needs with desired results.

To obtain credit, read the article, correctly answer the Posttest question, and complete the Evaluation.

CME Objective

After studying this article, you should be able to:

‘ ¢ Adopt appropriate strategies for communicating with African American patients with ADHD about their diagnosis and treatment

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The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

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The CME Institute of Physicians Postgraduate Press, Inc., designates this journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note: The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hour of Category I credit for completing this program.

Date of Original Release/Review

This educational activity is eligible for AMA PRA Category 1 Credit™ through May 31, 2017. The latest review of this material was January 2015.

Financial Disclosure

All individuals in a position to influence the content of this activity were asked to complete a statement regarding all relevant personal financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. In the past year, Alan J. Gelenberg, MD, Editor in Chief, has been a consultant for Zynx Health and Bloom Burton, has received grant/research support from Pfizer, and has been a stock shareholder of Healthcare Technology Systems. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure appears with the article.

J Clin Psychiatry 2015;76(5):592-596 (doi:10.4088/JCP.13008co6c)

This Commentary section of The Journal of Clinical Psychiatry presents the highlights of the planning teleconference series “Challenges in the Recognition and Management of ADHD in African American Adults in the United States,” which was held in April and May 2014. This report was prepared and independently developed by the CME Institute of Physicians Postgraduate Press, Inc., and was supported by an educational grant from Shire.

The teleconference was chaired by Anthony L. Rostain, MD, Department of Psychiatry and Pediatrics and the Adult Developmental Disorders Section, University of Pennsylvania Perelman School of Medicine, Philadelphia. The faculty were J. Russell Ramsay, PhD, Department of Psychiatry and the Adult ADHD Treatment and Research Program, University of Pennsylvania Perelman School of Medicine, Philadelphia; and Roberta Waite, EdD, PMHCNS-BC, FAAN, Department of Nursing, Assistant Dean of Academic Integration and Evaluation of Community Programs, Drexel University College of Nursing and Health Professions, Philadelphia, Pennsylvania.

Financial disclosure: Dr Rostain is a consultant for Biobehavioral Diagnostics, Pearson, Alcobra, and Shire; has received grant/research support from AHRQ and SUNY Upstate; is a member of the speakers/advisory board for Biobehavioral Diagnostics and Pearson; and has received royalties from Routledge/Taylor & Francis. Dr Ramsay is a consultant for Shire; has received honoraria from the Pennsylvania Psychological Association; and has received royalties from Routledge/Taylor & Francis and the American Psychological Association. Dr Waite has no personal affiliations or financial relationship with any commercial interest to disclose relative to the activity.

The opinions expressed herein are those of the faculty and do not necessarily reflect the opinions of the CME provider and publisher or the commercial supporter.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder associated with symptoms of inattention, hyperactivity, and impulsivity.1 When ADHD persists into adulthood, patients often experience occupational and social impairments and may present with mood, anxiety, or substance use disorders.2 Despite the deleterious effects of ADHD, many adults, especially minority patients, remain undiagnosed and untreated.3

Converging factors contribute to this problem, including population-specific characteristics such as a lack of knowledge of ADHD and access to care, as well as health care system-related issues such as a lack of culturally competent providers and stereotyping or biases.4 To provide culturally competent care for African American adults with ADHD, clinicians must understand the prevalence of adult ADHD, use a multifaceted diagnostic approach when assessing patients for ADHD, and individualize treatment plans by effectively collaborating with patients and their families.

Prevalence of ADHD in African American Adults

Limited data are available regarding the prevalence of ADHD among African American adults. One study5 of working adults between the ages of 18 and 44 years found that 1.4% of African Americans are estimated to have ADHD. According to another report, an estimated 4.4% of adults in the United States have ADHD, with almost 2% of African American adults having the disorder.6

Due to the lack of research that includes minorities, the African American community is viewed as a uniform group, but, in reality, many different communities exist. Hopefully, future research will provide a more nuanced view of how ADHD affects various groups of African Americans.

Assessment of ADHD in African American Adults

Clinicians should assess for signs or symptoms of ADHD in adults who are facing recurring problems related to job loss, relationships, reckless behavior, or social rejection.7 Many adult patients will not recognize the source of their problems, which is why clinicians should use a multifaceted diagnostic approach to screen for ADHD. Because no single tool or laboratory test currently exists for diagnosing ADHD, formal diagnosis should be made using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM), clinical assessment, rating scales, and, if warranted, neuropsychological tests.

DSM Criteria

While the DSM criteria for ADHD provide the basis for diagnosis, clinicians must understand that its classification system was inherited from the 19th century European model that distinguishes diseases based on unique symptoms, etiology, course, and treatment, which were described using studies conducted mainly on middle-class white subjects.8 Psychiatric disorders, such as ADHD, however, are variably expressed across cultures. Clinicians must understand the magnitude of cultural and racial differences when assessing patients for mental health concerns.9 At the same time, clinicians must avoid stereotyping because the black population is heterogeneous and includes African American, Caribbean, and Hispanic populations.

The DSM-5 suggests that culture-related diagnostic issues may contribute to clinicians’ misjudging the severity of a problem or giving an inaccurate diagnosis.1 Cultural formulation, which is described as a framework for clinical evaluation, can help mitigate diagnostic errors that may occur from clinicians’ assumptions about symptoms, manifestation, expression, and course.1 The DSM-5 provides 2 cultural formulation interviews, which may be administered by clinicians to the patient or an informant.

Clinical Assessment

Clinical assessment should include symptoms, level of impairment, developmental history (including developmental comorbidities), family history, educational history, psychological testing, collateral history, and the individual history, including cultural and contextual factors. In adults, inattention is the predominant symptom, which can include disorganization, unreliability, forgetfulness, inefficiency in planning, inability to complete tasks and trouble with task shifting, and time management issues.1 Hyperactivity may diminish in adults, but symptoms may include moving one’s hands and feet, feeling restless, talking excessively and interrupting others, and having poor impulse control. The patient must have had several inattentive or hyperactive/impulsive symptoms present before age 12 years.1 Symptoms must be present in 2 or more settings (home, school, work, or social events), must interfere with or reduce the quality of functioning, and cannot be explained better by another diagnosis.

Rating Scales and Collateral Reports

Adults with ADHD may have developed coping strategies to compensate for their symptoms, and they may have symptoms that overlap with those of other conditions. Because these factors can hinder recognition of ADHD, clinicians may be assisted by the use of screening and diagnostic instruments designed specifically for adults.2

Several clinician- and self-administered ratings scales are available to aid the assessment of ADHD in adults. These scales supplement the clinical interview but should never replace it.2 One scale is the clinician-administered Conners Adult ADHD Diagnostic Interview, which includes questions regarding both childhood and adulthood ADHD symptoms, with examples, and a brief screen for comorbidities.2 The Adult ADHD Self-Report Scale (ASRS) V1.1 is a screening instrument that assesses the frequency of symptoms.2

In addition to rating scales, diagnosis of ADHD typically requires informant reports.1 For many African Americans, family is their main support system, and including family members in a patient’s assessment and treatment, with the patient’s permission, may be helpful.10 On rating scales, however, patients’ and informants’ feedback is influenced by their own cultural filters and “historical concepts,” or the meaning and interpretation that individuals assign to their histories. Mental health care practitioners regularly obtain a present, past, and family history of illnesses from their patients. Providers must also explore patients’ and families’ historical concepts, as being “history sensitive” is a fundamental way in which providers can reduce African Americans’ cultural mistrust of the mental health care system.

clinical points
  • Diagnose ADHD using DSM criteria, clinical interview, rating scales, and informant reports.
  • Treat adult ADHD with appropriate pharmacotherapy, psychotherapy, or both.
  • Guard against bias and stereotyping African American patients.
  • Provide education on ADHD to patients, their families, and communities.

Neuropsychological Tests

Neuropsychological tests may be used to evaluate impairments in attention and executive function, learning, and processing speed.11 Some common neuropsychological tests include the Stroop Color and Word Test, Trail Making Test, and Continuous Performance Test. While these tests can help quantify attentional and cognitive deficits, single test measures do not have adequate diagnostic value in ADHD.12

Treatment of ADHD in African American Adults

Clinicians should work closely with patients and their families to ensure that they avoid a cycle of blame, hopelessness, or self-defeating behaviors. Treatment may include pharmacotherapy, psychotherapy, or both, in addition to using alternative therapies or working with a pastor.

Pharmacotherapy

Pharmacotherapy is typically the first-line treatment for ADHD, but many factors must be taken into consideration when assessing each patient’s case.7 Clinicians must recognize that, in general, African Americans have low utilization of stimulants, which may stem from mistrust or fear of addiction.13 Stimulants that are adequately dosed for adults improve symptoms in about 70% of patients.7 However, due to their potential for abuse or diversion, stimulants should not be prescribed for patients with current substance abuse or who may sell the drug.7 Nonstimulant medications or antidepressants may be used for patients who cannot tolerate or are resistant to stimulants.7 Medical history should also be considered.

Psychotherapy

For African American adults with ADHD who cannot or will not take medication, other treatment approaches are necessary. Psychotherapy may be used to help patients cope with problems related to sustained attention, inhibitory control, working memory, and motivation, problems that may contribute to the core ADHD symptoms of inattention, hyperactivity, and impulsivity.14 Cognitive interventions may also target negative thought patterns and emotions that lead to patients’ continued failure and underachievement.14

Examples of psychotherapy include cognitive-behavioral therapy (CBT), mindfulness meditation training, and group metacognitive therapy. A review14 of CBT for adults with ADHD revealed that repetition and reinforcement of targeted compensatory skills for core symptoms were key elements of successful therapy versus interventions that covered too wide a range of topics. In addition, CBT combined with medication has proved effective for reducing ADHD symptoms, depression, and anxiety in patients with residual symptoms.15 As an adjunct to pharmacotherapy, psychosocial therapy can help patients with ADHD improve functional performance and maximize benefits from medication.16 A pilot study17 demonstrated that both CBT with placebo and CBT with medication improved core ADHD symptoms and functioning, with no significant differences between the groups (Figure 1).17 This study suggests that CBT alone can be as effective as CBT with medication for adults with ADHD.

Figure 1

Click figure to enlarge

A culturally congruent model of therapy for African Americans is the Intersystem model, which is an integrated and comprehensive model that assimilates properties from not only the individual but also interactional and intergenerational patient systems.18 This model offers a contextual framework to help assess and treat many complex problems that arise from ADHD. One of the many strengths of the Intersystem model is that it recognizes the complexity of the person’s life, relationships, and problems and supports these multiple viewpoints.

During treatment, therapists must confront any stereotypes they have regarding African Americans. This process should be done before and throughout the relationship with patients.19 The patient’s race is critical, and conversation about it should not be avoided because what is unsaid can seep into other areas of the relationship between patient and therapist. Furthermore, therapists should be cognizant of the patient’s needs and should discuss the patient’s expectations of the therapy and its course.

Throughout treatment, therapists should focus on patients’ strengths, such as resilience and optimism, and social supports, including friends and family. Given the importance of family, the use of multiple family groups can be effective in treatment for African Americans affected by ADHD. Different family members may come together with other families to learn and support one another. Clinicians should also be sensitive to gender alliance, as well as draw on the individual’s religion if that may be beneficial.

Strategies to Promote Culturally Competent Care

Culturally competent care involves the delivery of mental health services that are respectful of and responsive to the health beliefs, practices, and needs of African American patients.20 Cultural competence has a positive effect on patient care and is a critical element in reducing health disparities and improving access to high-quality care.20

One way to improve cultural competence is for clinicians to learn to recognize and manage biases. Clinicians should consider their own biases, the biases that patients might have, and what they can do to increase the likelihood of providing evidence-supported treatment that takes into account patients’ concerns and cultural beliefs. Empathizing with patients’ concerns and being nondefensive while providing evidence-based explanations about symptoms and treatment options are both important. Clinicians should also be prepared to anticipate questions and doubts based upon patients’ cultural beliefs. If a patient appears uncomfortable, clinicians can offer inviting statements such as, “I have had a lot of people who were concerned about X, Y, or Z,” which may open the lines of communication.

While explaining a treatment plan, clinicians should acknowledge the limitations of various treatment options and inform patients as to what behavioral treatments, psychosocial treatments, and medications can provide in terms of symptom control and prognosis. Clinicians must be willing to start small rather than take an all-or-nothing approach. For example, someone who refuses medication may be willing to start with a behavioral treatment.

CONCLUSION

ADHD causes significant functional impairment in adults if left undiagnosed and untreated. More research is needed to clarify the prevalence and effects of ADHD in African American groups. African American adults may not recognize their symptoms due to a lack of knowledge or because they have developed coping strategies. Clinicians should use a multifaceted diagnostic approach when assessing adult patients for ADHD. This approach should incorporate DSM criteria, a thorough clinical interview, and rating scales such as the ASRS. Comorbid conditions must also be confirmed or ruled out, as many conditions have overlapping symptoms with ADHD. Treatment for ADHD includes stimulant and nonstimulant medications, psychotherapy, or a combination of the two. Clinicians who take the time to listen and understand their African American patients’ background, beliefs, and concerns will be able to alleviate patients’ feelings of fear or mistrust. Clinicians must recognize and remove bias and look for ways to educate patients, their families, and communities regarding mental health disorders and their treatment. With a focus on culturally competent care, clinicians can better assess and treat their patients with ADHD, leading to improved symptoms and quality of life.

Drug name: dextroamphetamine (Dexedrine and others).

Disclosure of off-label usage: Dr Rostain has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration-approved labeling has been presented in this activity.

References

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2. Goodman DW. ADHD in adults: update for clinicians on diagnosis and assessment. Prim Psychiatry. 2009;16(11):21-30.

3. National Alliance on Mental Illness. ADHD and adults: a look at cultural differences. http://www.nami.org/Template.cfm?Section=ADHD&Template=/ContentManagement/ContentDisplay.cfm&ContentID=106391. Accessed January 21, 2015.

4. Bailey RK, Ali S, Jabeen S, et al. Attention-deficit/hyperactivity disorder in African American youth. Curr Psychiatry Rep. 2010;12(5):396-402. PubMed doi:10.1007/s11920-010-0144-4

5. Kessler RC, Adler L, Ames M, et al. The prevalence and effects of adult attention deficit/hyperactivity disorder on work performance in a nationally representative sample of workers. J Occup Environ Med. 2005;47(6):565-572. PubMed doi:10.1097/01.jom.0000166863.33541.39

6. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723. PubMed doi:10.1176/ajp.2006.163.4.716

7. Weiss M, Bailey R. Advances in the treatment of adult ADHD: landmark findings in nonstimulant therapy. Medscape. http://www.medscape.org/viewarticle/458059_1.

8. Aggarwal NK. From DSM-IV to DSM-5: an interim report from a cultural psychiatry perspective. The Psychiatrist. 2013;37(5):171-174. doi:10.1192/pb.bp.112.040998

9. Dana RH. Mental health services for African Americans: a cultural/racial perspective. Cultur Divers Ethnic Minor Psychol. 2002;8(1):3-18. PubMed doi:10.1037/1099-9809.8.1.3

10. Waite R, Ramsay JR. Adults with ADHD: who are we missing? Issues Ment Health Nurs. 2010;31(10):670-678. PubMed doi:10.3109/01612840.2010.496137

11. Woods SP, Lovejoy DW, Ball JD. Neuropsychological characteristics of adults with ADHD: a comprehensive review of initial studies. Clin Neuropsychol. 2002;16(1):12-34. PubMed doi:10.1076/clin.16.1.12.8336

12. Schoechlin C, Engel RR. Neuropsychological performance in adult attention-deficit hyperactivity disorder: meta-analysis of empirical data. Arch Clin Neuropsychol. 2005;20(6):727-744. PubMed doi:10.1016/j.acn.2005.04.005

13. Olaniyan O, dosReis S, Garriett V, et al. Community perspectives of childhood behavioral problems and ADHD among African American parents. Ambul Pediatr. 2007;7(3):226-231. PubMed doi:10.1016/j.ambp.2007.02.002

14. Knouse LE, Safren SA. Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder. Psychiatr Clin North Am. 2010;33(3):497-509. PubMed doi:10.1016/j.psc.2010.04.001

15. Safren SA, Otto MW, Sprich S, et al. Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behav Res Ther. 2005;43(7):831-842. PubMed doi:10.1016/j.brat.2004.07.001

16. Manos MJ. Psychosocial therapy in the treatment of adults with attention-deficit/hyperactivity disorder. Postgrad Med. 2013;125(2):51-64. PubMed doi:10.3810/pgm.2013.03.2641

17. Weiss M, Murray C, Wasdell M, et al. A randomized controlled trial of CBT therapy for adults with ADHD with and without medication. BMC Psychiatry. 2012;12(1):30. PubMed doi:10.1186/1471-244X-12-30

18. Weeks GR, Cross CL. The intersystem model of psychotherapy: an integrated systems treatment approach. Guid Counc. 2004;19(2):57.

19. Bell C, McBride DF. Psychiatry for People of African Descent in the USA. In: Parekh R, ed. The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health. New York, NY: Springer; 2014:139-163. doi:10.1007/978-1-4614-8918-4_6

20. National Institutes of Health. Cultural Competency. http://www.nih.gov/clearcommunication/culturalcompetency.htm. Reviewed June 3, 2014. Accessed January 21, 2015.

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