Health Care–Seeking Behaviors of African American ADHD Patients and Their Families: Overcoming Economic and Cultural Barriers
Anthony L. Rostain, MD
Department of Psychiatry and Pediatrics and the Adult Developmental Disorders Section, University of Pennsylvania Perelman School of Medicine, Philadelphia
A combination of economic and cultural issues (including myths and misinformation) influences health care–seeking behaviors among African Americans. African Americans compose about 12% of the US population, with more than 50% living in the South.1 Moreover, significant health disparities exist between the white majority and minority populations including African Americans, a culturally rich and diverse group that includes immigrants from Africa, the Caribbean, Central America, and other areas.2
Health disparities encompass differences in domains of health, such as illness incidence, access to care, and outcomes of care.1 Mental health conditions, such as depression and ADHD, can impact patients’ social and occupational functioning if they remain undiagnosed and untreated.3 To improve mental health care for African American patients, clinicians must recognize disparities and respond to barriers that hinder African Americans from receiving mental health care services.
Disparities in Health Care for African Americans
Several issues affect health care utilization among African Americans, especially income and health insurance coverage.
Income. The median income of African American households is less than two-thirds that of non-Hispanic white households, with 27% of African Americans living below the poverty level (compared with about 10% of non-Hispanic white people).4 The rate of poverty for rural African American households is triple the rate of rural non-Hispanic white households (40.6% and 13.5%, respectively).5 In 2012, the unemployment rate for African Americans was 14% compared with 7% in the white population.6
These disparities in income and employment are due to a variety of factors, such as educational attainment, patterns of racial segregation, and family composition. High school and college graduation rates can affect the earning potential of minority groups. The high school graduation rate for African American students in 2011–2012 was 69%, which was lower than the 88% rate for Asian and Pacific Islander students, 86% for non-Hispanic white students, and 73% for Hispanic students.7 Family composition also influences poverty levels because families with 2 adults will likely have more sources of income than single-adult families.5
Health insurance coverage. Lack of health insurance plays a large role in the inadequate health care of African Americans.2 The rate of uninsured African Americans in 2012 was 19% compared with 11% of non-Hispanic white people ().4 These percentages reveal startling disparities for African Americans, which affect their mental health care utilization. For example, only 6% of African American children had used mental health care services compared with 14% of white children, according to parents’ reports in a study of 5,147 US fifth graders.8 This study also showed that fewer African American and Hispanic children with recent symptoms of ADHD, ODD, or conduct disorder had used services compared with white children.8 While financial barriers such as low income and lack of health insurance contribute to disparities in health care, other barriers also influence treatment-seeking behaviors.9
AV 1. People Without Health Insurance Coverage by Race, 2012 (00:27)
Barriers to Mental Health Care Services for African Americans
The prevalence of mental illnesses is similar between African Americans and the general population, but African Americans have higher rates of phobias, PTSD, and chronic depression.1,2 African Americans often receive poorer quality care and lack access to culturally competent care.2
Access. The number and location of mental health care providers greatly influence the availability of treatment for African Americans.9 Generally, a shortage of mental health care providers exists throughout the United States,10 and fewer mental health care providers are located in rural areas, such as the South where many African Americans live.9 Additionally, a small minority of mental health providers are African American—fewer than 5% of psychologists, psychiatrists, and social workers.9 In 2012, the rate of past-year mental health treatment for adults with mental illnesses was 10% for African Americans and about 18% for white adults ().11 African Americans are more likely to seek health care from hospital emergency departments rather than outpatient offices that can provide better preventive treatment and follow-up care.9
AV 2. Past Year Mental Health Treatment by Race/Ethnicity: Percentages, 2012 (00:23)
Specific subpopulations within the African American community are at higher risk for mental illness, including people who are homeless, incarcerated, and supported by welfare. These subpopulations often have limited access to mental health care due to their poor socioeconomic status.9 Regarding access to depression treatment, 41% of African Americans received any treatment versus 60% for white patients, and adequate treatment rates were 12% for African Americans versus 33% for white patients.12 This difference is of particular significance because it speaks to disparities that exist in the actual delivery of care to those seeking help. Although the prevalence of ADHD among African American children is similar to that among white children (9.5% and 10.6% in 2009, respectively),13 white children are nearly twice as likely to receive ADHD medications.14 These rates indicate a need for improved access to care and more effective treatment and follow-up in African American patients.
Myths and misinformation. One possible reason for the lower rates of psychotropic medication usage among African Americans could be concern within the community about the medicalization of social problems. Many believe that the problem of hyperactive children results from insufficient school resources and from culturally insensitive teachers. Others lack an understanding about the nature of mental health disorders and about the benefits of evidence-based treatment. A sizeable percentage of African Americans fear that stimulant medications can lead to misuse, abuse, and addiction. Some believe that behavior problems related to ADHD are due to negative personality traits.3 Lastly, African Americans may mistrust health care providers or have concerns about provider competence with their racial group, especially if they have experienced mistreatment by a mental health professional.12
Mental illness is associated with considerable stigma among African Americans, which contributes to avoidance of diagnosis and treatment. Social stigma associated with seeking professional help is a significant barrier to treatment, and African Americans may rely mainly on family or friends when they have a problem.15 Fear of treatment or of hospitalization can also keep African Americans from visiting a mental health provider.9 African Americans tend to have a strong sense of pride, self-reliance, and family privacy, which are resilient qualities but which may also discourage people from seeking help. For example, “toughing it out” is advocated in African American culture during difficult times.15
Strategies to Improve Mental Health Care for African Americans
The first step toward improving mental health care among African Americans is to conduct stigma awareness training in every facet of society, including among religious leaders, health care providers, schools, and community groups and organizations.2 Everyone needs to understand how stigma surrounds mental illness and how it creates barriers to care. It is also important to talk openly about mental disorders, substance abuse, and the burdens these impose on individuals, families, and society so misconceptions can be addressed and corrected. Individuals living with a mental disorder in minority communities need the support of family and friends to help them overcome the isolation that social stigma imposes. In addition, clinicians can provide accurate, science-based information to family and friends of African American patients to help dispel the most common myths regarding mental illness.3
Second, clinicians need education on the disparities in health care between African Americans and other groups so they can advocate policies that promote care equity.2 For example, clinicians can advance policies that increase diversity in the mental health care workforce.16 Having more minority providers could improve access to care and build trust between African American patients and providers.16 Policies that ensure comprehensive, affordable health coverage should help reduce the number of uninsured people as the recent passage of the Affordable Care Act seems to be doing. Clinicians also need to be aware of the link between mental health disorders and chronic disease because patients with both face more challenges staying healthy and adhering to treatment.2 Clinicians can also benefit from education on how to better understand the circumstances and symptom reports of minority patients.16
Third, clinicians should help increase community awareness of services to improve access, utilization, and follow-up, including among high-risk populations such as those who are homeless, incarcerated, and unemployed.2
Finally, a focus on prevention and early intervention will help patients deal with mental health conditions before they become chronic problems.2 While no single solution can reduce health disparities, clinicians can help by improving access to quality health care; by providing education to African American patients, families, and communities; and by learning culturally competent strategies for managing patients of different races.
Many African Americans are not receiving mental health care for conditions that influence their social and occupational functioning, such as depression and ADHD. Many disparities in the receipt of health care by African Americans stem from low income and lack of insurance; however, other barriers exist. Access to providers is one barrier, along with concerns about treatment and attitudes such as stigma, fear, and mistrust of the medical community. Clinicians can help overcome these barriers by providing education on mental illness and treatment, eliciting support from the African American community and their leaders, and focusing on prevention and early intervention.
- Recognize how disparities in income and health insurance can hinder African Americans from receiving care
- Ascertain whether barriers that block access to care or specific attitudes or misconceptions are keeping African Americans from obtaining mental health care
- Provide education on mental health disorders, their treatments, and support services to African American patients, families, and communities
ADHD = attention-deficit/hyperactivity disorder
ODD = oppositional defiant disorder
PTSD = posttraumatic stress disorder
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- Trujillo M. Multicultural aspects of mental health. Prim Psychiatry. 2008;15(4). Full text
- American Psychiatric Association. APA Fact Sheet: Mental Health Disparities: African Americans. http://www.psychiatry.org/File%20Library/Practice/Diversity/Diversity%20Resources/Fact-Sheet---African-American.pdf. Published 2014. Accessed September 29, 2014.
- 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 September 29, 2014.
- DeNavas-Walt C, Proctor BD, Smith JC. Income, Poverty, and Health Insurance Coverage in the United States: 2012. Washington, DC: US Government Printing Office; 2013. http://www.census.gov/prod/2013pubs/p60-245.pdf.
- US Department of Agriculture. Rural Poverty and Well-being: Poverty Demographics. www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/poverty-demographics.aspx. Updated September 30, 2013. Accessed September 29, 2014.
- US Bureau of Labor Statistics. Labor Force Characteristics by Race and Ethnicity, 2012. Washington, DC: US Dept of Labor; October 2013. Report 1044. www.bls.gov/cps/cpsrace2012.pdf.
- Stetser MC, Stillwell R. Public High School Four-Year On-Time Graduation Rates and Event Dropout Rates: School Years 2010–11 and 2011–12. Washington, DC: US Dept of Education; April 2014. NCES 2014-391. www.nces.ed.gov/pubs2014/2014391.pdf.
- Coker TR, Elliott MN, Kataoka S, et al. Racial/ethnic disparities in the mental health care utilization of fifth grade children. Acad Pediatr. 2009;9(2):89–96. PubMed
- US Department of Health and Human Services. Mental Health Care for African Americans. In: Mental Health: Culture, Race, and Ethnicity: a Supplement to Mental Health: a Report of the Surgeon General. Rockville, MD: US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001.
- Kaiser Family Foundation. Mental Health Care Health Professional Shortage Areas (HPSAs). http://kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas. Updated April 28, 2014. Accessed September 29, 2014.
- Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Mental Health Detailed Tables. Published 2012. Accessed September 29, 2014.
- Alegría M, Chatterji P, Wells K, et al. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv. 2008;59(11):1264–1272. PubMed
- Akinbami LJ, Liu X, Pastor PN, et al. Attention deficit hyperactivity disorder among children aged 5-17 years in the United States, 1998-2009. NCHS Data Brief. 2011;70:1–8. PubMed
- Jonas BS, Gu Q, Albertorio-Diaz JR. Psychotropic Medication Use Among Adolescents: United States, 2005–2010. NCHS Data Brief. 2013;135:1–8. PubMed
- Vogel DL, Wester SR, Larson LM. Avoidance of counseling: psychological factors that inhibit seeking help. J Couns Dev. 2007;85:410–422. Abstract
- McGuire TG, Miranda J. New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Aff (Millwood). 2008;27(2):393–403. PubMed