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Health Care Systems Issues and Disparities in ADHD Care for African American Adults

J. Russell Ramsay, PhD

Department of Psychiatry and the Adult ADHD Treatment and Research Program, University of Pennsylvania Perelman School of Medicine, Philadelphia

Many converging factors contribute to the underdiagnosis and undertreatment of African American adults with ADHD, including population-specific characteristics as well as health care system-related issues.1 This article focuses on health care systems issues and disparities in care for African American adults with ADHD.

Prevalence of ADHD in African American Adults

Thus far, most data on racial or ethnic differences among adults with ADHD come from studies of children, usually male, and are extrapolated to adults. Due to the lack of research, the African American community is viewed as a uniform group, but, in reality, many different communities exist among African Americans. Hopefully, future research will provide a more nuanced view of how ADHD affects various groups of African Americans.

AV 1. The Sociodemographics of Adult ADHD (00:59)

Data from Kessler et al2

One study2 of US adults showed that 4.4% are estimated to have ADHD, but, of those, only 6.2% are African Americans, meaning that 1.9% of US African American adults have ADHD (AV 1).2 A similar study3 looked at adults between the ages of 18 and 44 years in the workplace and found that 1.4% of African Americans are estimated to have ADHD. So, the adult studies display a much lower prevalence of ADHD among African Americans than the child studies do.

Health Care System Barriers to Treatment

Several limitations exist in providing care for African American adults with ADHD and for adults with ADHD in general. Kessler and colleagues2 reported that, among US adults with ADHD, only 11% received treatment for it in the past year. Screening information for “gateway” contacts, such as educators and family physicians, may need improvement. Many primary care physicians are not comfortable with the diagnosis and treatment of ADHD.4 If specialty care is recommended, a lack of ADHD specialists, particularly for adult ADHD, is typical in most communities (AV 2).5 And, in any specialty, a lack of culturally competent specialists can occur.6 Furthermore, if care is available, barriers to care, depending on socioeconomic and insurance status, include having no means to pay the costs associated with it and being unable to manage the logistics of getting to and following through on a comprehensive evaluation and follow-up treatment. Ideal treatment for many individuals may be a combination of psychosocial and pharmacologic treatment,7 which means coordinating several appointments with different providers.

AV 2. Unmet Need for Mental Health Professionals in US Counties (00:47)

Data from Thomas et al5

Health Care Professionals’ Biases

Numerous biases might influence how a health care professional views ADHD in African American patients. One such bias is a belief that ADHD symptoms are the fault of the individual or of his or her environment. Physicians may believe that behavior that results from underlying ADHD is instead the result of individual shortcomings, particularly in adults, as it is associated with violation of social norms (eg, interrupting others, being reckless).8 A tendency also exists to overestimate environmental factors (such as poor parenting, poor education) that may contribute to the manifestation of ADHD behaviors and to underestimate actual illness.8 For example, a health care professional may think, “The school district is bad, so that is why I’m seeing these problems in this patient.” While environment should be a consideration in making the diagnosis, it can also be part of a bias that might lead to underdiagnosis.

ADHD symptoms in some patients may also be viewed as a behavioral issue, not a clinical issue, requiring only nonclinical support such as seeking help from a pastor or school counselor. Getting help from those resources can be beneficial in adults with ADHD, and possibly even indicated, but it may not be all that is required. Additionally, the symptoms may be viewed as stemming from another behavioral or clinical issue requiring nonspecialty support or counseling. The patient may be advised to see a therapist, but if the ADHD diagnosis is lacking, specialty care may not be sought.

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Improving Access to Care

One way to improve access to care is for clinicians to learn to recognize and manage biases. Clinicians should consider 3 main factors: 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-supported 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 seems to feel 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.9

Numerous factors can help improve access to care for African Americans with ADHD, one of which is community education addressing the myths about the disorder and its treatment.10 In awareness campaigns, African Americans with ADHD are needed as spokespeople to give a face to the disorder. Several celebrity ADHD spokespeople raise awareness, including TV host Ty Pennington, baseball player Shane Victorino, and singer Adam Levine, but African American spokespeople are needed, too. Additionally, education for gateway contacts is needed wherever people will first seek help, such as churches, schools, and primary care offices. The gateway contacts should be provided with accurate information and appropriate screening instruments (such as the WHO 6-item ASRS screener) and referral information, so they can help steer people in the right direction.11

Improving access to care also requires making workshops and training available to community health centers.10 The availability of remote access to expert case consultation services (eg, REACH) is also important. Additionally, training the next generation of clinicians, including specialists in ADHD, to increase their cultural competency and recruiting African American clinicians to that specialty will aid in improving care.

Conclusion

Research is lacking regarding African American adults with ADHD. Additionally, many barriers exist within the health care system, including limited availability of specialty services. Furthermore, even when patients are connected with medical services, barriers to an accurate diagnosis and treatment plan exist, based on patients’ cultural beliefs and clinicians’ implicit biases. Good models to overcome those challenges are becoming increasingly available. Many opportunities for improvement exist, and it will take a concerted effort from patients, community gateway contacts, and clinicians to close the loop to offering better treatment for African Americans with ADHD.

Clinical Points

  • Think about any racial biases you may have and how they could affect ADHD diagnosis and treatment decisions for your African American patients
  • Seek training about ways to improve your cultural competence
  • Provide community gateway contacts accurate information, appropriate screening instruments, and referral information
  • Empathize with patients’ concerns and be nondefensive while providing evidence-supported explanations about symptoms and treatment options for patients

Abbreviations

ADHD = attention-deficit/hyperactivity disorder

DSM = Diagnostic and Statistical Manual of Mental Disorders

References

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  2. 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
  3. 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
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  5. Thomas KC, Ellis AR, Konrad TR, et al. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60(10):1323–1328. PubMed
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  8. Mueller AK, Fuermaier AB, Koerts J, et al. Stigma in attention deficit hyperactivity disorder. Atten Defic Hyperact Disord. 2012;4(3):101–114. PubMed
  9. Ramsay JR, Rostain AL. CBT without medications for adult ADHD: an open pilot study of five patients. J Cogn Psychother. 2011;25(4):277–286. Abstract
  10. Bailey RK, Owens DL. Overcoming challenges in the diagnosis and treatment of attention-deficit/hyperactivity disorder in African Americans. J Natl Medical Assn. 2005;97(suppl 10):5S–10S. PubMed
  11. Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35(2):245–256. PubMed
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