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Health Care System​s Issues and Disparities in ADHD Care for Hispanic Adults

Yamalis Diaz, PhD

Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York

Adult Hispanics with ADHD encounter numerous barriers when seeking treatment. First, as adults with ADHD, they face the same obstacles surrounding diagnosis and treatment that confront all adults with ADHD, and second, as Hispanics, they may face additional cultural hurdles. Although ADHD is considered a disorder of childhood, for most individuals, symptoms will persist into adulthood.1 Making an adult diagnosis is challenging because information about childhood symptoms may be difficult for patients to recall or obtain, particularly for individuals who grew up outside the US. Many adults with ADHD remain undiagnosed.2 For Hispanic adults, cultural and instrumental barriers that prevent them from accessing care for ADHD comprise factors ranging from language barriers to cultural beliefs about mental health in general (AV 1).3

AV 1. Barriers to ADHD Service Use by Hispanic Adults (00:45)

 

Cultural Barriers to ADHD Service Use

Many of the barriers that prevent some Hispanic adults from receiving care for ADHD can be considered cultural. When discussing culture, however, one must keep in mind that culture is more than racial or ethnic group membership.3 Racial and ethnic groups are heterogeneous and vary widely depending on numerous variables including country of origin, traditions, values, beliefs, language, and even neighborhood characteristics. For instance, the culture of Cubans living in Miami can vary greatly depending on whether they live in high- or low-income communities. Generalizations cannot be made that apply to all members of any cultural group.

Treatment-seeking has been found to be influenced by an individual’s cultural background.4 Before seeking treatment, one must recognize that a problem exists,5 but many Latino and Hispanic individuals have cultural beliefs and values that do not recognize ADHD symptoms as problematic.3 These individuals, therefore, do not seek treatment. Hispanics may also fail to seek treatment because of a general lack of knowledge about mental illness, particularly ADHD (AV 2).3 Acculturation level has been found to affect how Hispanic individuals perceive ADHD symptoms, particularly impulsivity and hyperactivity,6 and to affect treatment preferences. Less acculturated Hispanics may prefer natural or holistic approaches over prescription medications and may rely on folk healers, or curanderos. Espiritismo, or the idea that spirits can impact health, is not uncommon among less acculturated Hispanics.3 Clinicians, therefore, must be mindful of the level of a patient’s acculturation and sensitive to cultural beliefs that may be deeply rooted.

AV 2. Differences Between Hispanic and White Survey Respondents Regarding ADHD (00:37)

Data from Rothe3

Hispanics may avoid treatment for ADHD because negative cultural views of mental illness and mental health treatment are common. Stigma surrounds mental illness, and individuals fear being labeled as “crazy.”7 Negative views and misperceptions of psychotropic drugs are also common, such as the idea that these drugs are ineffective or addictive, or that the use of these drugs is indicative of severe mental illness. Hispanics may also feel that mental health issues should be managed within the family or left to God to resolve.

Finally, Hispanic individuals sometimes fail to seek treatment because of general mistrust of or negative attitudes toward mental health providers. Hispanics place great value on the idea of personalismo, which is a positive relationship or rapport with health care providers.8 They do not want to feel like they are just another patient. Until this rapport is established, Hispanic patients may refrain from asking questions and may not appear fully engaged in the assessment and treatment process. They may even pretend to understand and agree with the clinician’s recommendations, when they actually have many questions and concerns. In addition, many Hispanics, particularly if they have immigrated illegally, may be reluctant to interact with the health care system for fear of deportation. Immigration may also have been a traumatic experience, which can have an impact on symptom presentation and potential comorbidities.

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Instrumental Barriers to ADHD Service Use

Perhaps the greatest instrumental barrier to ADHD service use among Hispanics is language. Assessment interviews and instruments were developed in English and for use with children, so when they are translated into Spanish and used with adults, the symptoms and criteria may no longer be valid.9 The translation may be too literal or may use terms that do not make sense across cultural groups. For example, the ADHD symptom of acting as if “driven by a motor” does not translate well and therefore may not make sense to a Hispanic patient.

AV 3. People Without Health Insurance Coverage by Race, 2012 (00:51)

Data from DeNavas-Walt et al10

A general lack of Spanish-speaking mental health providers exists and constitutes a major barrier to service use in Hispanic patients. Translators are sometimes used to overcome language barriers, but problems still arise when translators simply translate what a doctor or patient says without considering context or meaning, leading to doctors not fully understanding the symptoms a patient is reporting or a patient not understanding what the doctor is trying to say. Translators may not be adequately trained or may be trained in medical diseases but not in mental health concerns. If formal translation services are not available, patients may use their children or other family members as interpreters, but this can also lead to mistranslation and can limit the ability of clinicians to gather important information. Similarly, because of a lack of translated educational materials about ADHD, clinicians often cannot provide information for patients to read, meaning that all treatment options must be discussed verbally, again potentially and literally getting lost in translation. Lack of insurance is also a considerable barrier to service use in Hispanic populations. Nearly a third of Hispanics living in the United States do not have health insurance,10 which is nearly 3 times the proportion of uninsured among the non-Hispanic white population (AV 3).

Clinical Implications for Cultural Competence

Although clinicians need to draw on their knowledge of Hispanic cultural beliefs and values in the treatment process, they must also be careful to avoid stereotyping. Clinicians must remember to consider the patient’s country of origin, education and acculturation level, immigration status, mental health history, and other factors that make the patient a unique individual. Clinicians must also remember the importance of personalismo and strive to establish a positive rapport with Hispanic patients, engaging them in the treatment process, so that they feel more comfortable asking questions and discussing their beliefs. Clinicians may also benefit from asking Hispanic patients their beliefs about the nature and cause of their symptoms, possibly avoiding the use of the term symptoms entirely. Instead, clinicians should consider addressing ADHD in terms of functional impairment rather than as a list of symptoms and provide concrete examples of how ADHD affects functioning. Hispanic patients may be more willing to participate in treatment if they understand the specific problems that ADHD may be causing in their lives. Treatment goals should be clearly linked to the areas of identified impairment.

Clinicians should seek to identify and address any inaccurate ideas about the nature of ADHD, particularly any spiritual or supernatural beliefs, and misperceptions about treatment. This process must be done in a culturally sensitive manner, and the patient’s values and beliefs must be respected and considered when establishing treatment goals and devising a treatment plan.

Finally, clinicians should assess common instrumental obstacles to treatment, such as lack of insurance, language barriers, and transportation or scheduling constraints, and discuss possible solutions with the patient. For example, for patients without insurance, free or low-cost insurance options or voucher programs might be available, and, for Spanish-speaking patients, Spanish-language educational materials and well-trained translators should be provided. By considering each patient’s unique needs, clinicians will be able to provide optimal care to their adult Hispanic patients with ADHD.

Clinical Points

  • Be considerate of Hispanic patients’ cultural values and beliefs but avoid racial or cultural stereotypes
  • Provide Hispanic patients with printed materials in Spanish and provide well-trained translators if possible
  • Engage Hispanic patients in the treatment process by establishing personalismo, or a positive personal rapport
  • Refer to functional impairment rather than symptoms when making a diagnosis and discussing treatment goals
  • Consider and address common barriers to treatment among Hispanic patients such as fear of deportation, problems with transportation or scheduling constraints, and lack of insurance

Abbreviation

ADHD = attention-deficit/hyperactivity disorder

References

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