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Culturally Competent Approaches to Diagnosing ADHD in Hispanic Adults and Overcoming Cultural Issues With Patients and Families

Juan Pedraza, MD

Department of Psychiatry, Moun​t Sinai School of Medicine, New York, New York

Hispanics are the most prevalent minority in the US1 and comprise a diverse population. Hispanics differ in numerous ways, from their country of origin to their socioeconomic status and English language proficiency. The common disorder ADHD affects about 4% of adults, where it may be unrecognized and untreated, causing substantial role impairment.2 Clinicians need to be familiar with the unique characteristics and needs of Hispanic individuals with ADHD and use this knowledge to provide culturally competent diagnosis and treatment.

Building Cultural Competence About Hispanics With ADHD

Hispanics in the US come from several different regions of Latin America, including Central and South America, the Caribbean Islands, and Mexico (AV 1).3 Mexicans are the most prevalent Hispanic group in the US, with the highest concentrations in California and Texas.3

AV 1. Region of Origin of US Hispanics (00:42)

Data from Ennis et al3

A Hispanic individual’s country of origin may be important for several reasons. Hispanics from countries closer to the US may have fewer acculturation issues due to the proximity of their homeland to this country. Many countries in Latin America have recent histories of ongoing armed conflict, which can lead to a history of trauma in individuals from these regions. Country of origin is also correlated with migratory status, language proficiency, and educational attainment. For example, Puerto Ricans in the US have the largest numbers of native-born citizens (individuals born in Puerto Rico are US citizens) and the largest percentage of English proficiency, whereas Central Americans have the highest rates of noncitizenship and the poorest English proficiency (AV 2).4 Compared with other Hispanic groups, Central Americans and Mexicans also have the lowest levels of educational attainment.4 Finally, cultural values and beliefs can vary widely depending on an individual’s region of origin, and these cultural differences can influence an individual’s attitudes toward the diagnosis and treatment of ADHD.

AV 2. Language Spoken at Home and English Proficiency by People of Hispanic Origin in the US, 2000 (00:28)

Data from Ramirez4
*Average of Puerto Rican, Cuban, and Dominican responses

Culturally Competent Methods for Diagnosing ADHD in Hispanic Adults

ADHD is a disorder that is largely understood within a cultural and social context. Adults with ADHD are generally expected to have low academic and occupational attainment, to frequently be divorced or have a history of failed relationships, to have a history of traffic violations or legal difficulties, and/or to have a high incidence of substance abuse and comorbid disorders.2,5 Although these characteristics are common in adults with ADHD, they may not accurately reflect Hispanic adults with ADHD. ADHD presentation can vary greatly depending on the patient’s history and family background.6 Clinicians, therefore, must be alert for varied ways that ADHD may manifest in Hispanic patients.

When conducting an interview, clinicians must keep several factors in mind that may be unique to Hispanic patients with ADHD. The economic and political situation in the patient’s country of origin may have exposed the patient to armed conflict or extremely depressed economic conditions, which may create a history of trauma and associated disorders.7 The clinician also needs to know a patient’s current immigration and economic status, and whether the individual has insurance, because this can affect the patient’s ability to come to appointments or obtain medication.

AV 3. Comparison of Available Rating Scales for ADHD in Adults (00:37)

Based on Adler and Cohen,13 Taylor et al,9 and Kessler et al11

A diagnosis of ADHD in any patient is rendered using a clinical interview and various rating scales (AV 3).8 Self-report scales commonly used to assess for ADHD in adults include the Brown ADD scale, the Conners Adult ADHD Scale, and the Adult Self Report Scale V1.1.9 Although these scales have been tested in adult populations,9 they may not be effective in Hispanic populations. Hispanic patients who are not proficient in English may have difficulty understanding the questions and ratings, or the scales may use assessments that do not accurately reflect conceptions of ADHD symptoms and disabilities that are common in Hispanic cultures. For example, Gerdes and colleagues10 administered a Spanish version of the Disruptive Behavior Disorders rating scale to Latino mothers to assess for ADHD in their children. This study found that in a Latino population, the hyperactive/impulsive subscale was not culturally appropriate. Although this study focused on children and not adults, it illustrates the importance of considering language proficiency and cultural background when conducting a clinical interview with a Hispanic patient.

With Hispanic patients, semi-structured clinician-administered interviews, such as the Adult ADHD Clinical Diagnostic Scale (ACDS),11 that address both childhood and adult symptoms may be the best option, but clinicians must carefully discuss the questions and ratings with the patient and be aware that patients may underreport their symptoms or impairment. Clinicians must also be considerate of the patient’s background. For example, the ACDS includes the question, “Was your desk or locker at school a mess?” This question would not be appropriate for an individual who has been working since early childhood or who was unable to attend school because of economic difficulties. Thus, when asking questions related to childhood experiences, the clinician must always keep in mind the conditions in which the patient grew up. For questions related to adult symptoms and functioning, consideration of the current demands that the patient is likely experiencing is also important when evaluating responses to question such as, “Do you have trouble with detailed work?” These considerations are important when using any type of assessment scale with Hispanic patients.

More

Best Practices for Treating ADHD in Hispanic Adults

When providing treatment to Hispanic patients, clinicians must continue to keep in mind the heterogeneous nature of the Hispanic population and be alert for communication barriers. If patients have limited English proficiency, a translator may be needed. Clinicians should provide simple explanations and avoid statements or questions that involve complex ideas or nuanced understandings that do not translate well. In addition, the cultural meaning of some questions may be different for Hispanic patients.

Because many Hispanic individuals who have come to the US from Latin America may have a history of trauma associated with conditions in their native country or the process of emigrating,7 clinicians should always assess for comorbidities and adjust treatment accordingly. For example, intergenerational poverty may manifest as domestic violence or substance abuse, while individuals who experienced discrimination or forced assimilation in their country of origin may fear the legal system or the loss of their culture.7 Because many Hispanic patients may lack health insurance, information about voucher programs or other low-cost health services should be provided, and clinicians should attempt to prescribe the most affordable treatments that are likely to be effective.

Finally, when treating Hispanic adults with ADHD, clinicians must follow established best practices for treating all adults with ADHD, such as avoiding short-acting stimulants to limit the possibility for diversion and drug dependence or abuse, using simple medication regimens to improve adherence, addressing side effects, and providing psychosocial interventions when appropriate, particularly in the presence of comorbidities.8,12 Frequent follow-up visits are effective for assessing progress and building rapport, which is particularly important to Hispanic patients. Clinician-administered rating scales rather than self-report scales should be used to monitor progress. Rating scales such as the AISRS and ACDS allow greater communication between clinicians and patients, which can build rapport, identify any language barriers, and ensure questions are understood by Hispanic patients.

Conclusion

When treating Hispanic adults with ADHD, clinicians must combine what they know about treating ADHD in adults in general with a culturally competent understanding of the special needs of Hispanic patients. Hispanic culture is heterogeneous, so clinicians must ask all Hispanic patients about their background and current circumstances, determine their degree of English proficiency, and assess barriers that may prevent them from obtaining treatment, such as lack of insurance. Clinicians should then use this information to provide accessible and effective treatment.

Clinical Points

  • Ask patients about their social and cultural background to increase understanding of their special needs and potential barriers that might exist to treatment
  • Evaluate each patient’s English proficiency and carefully discuss interview and rating scale questions to ensure that they are understood
  • Assess for comorbid psychiatric conditions
  • Recommend treatments that are accessible and affordable to Hispanic patients, keeping in mind that many may lack insurance and have limited resources to obtain treatment

Abbreviations

ACDS = Adult ADHD Clinical Diagnostic Scale

ADD = attention deficit disorder

ADHD = attention-deficit/hyperactivity disorder

AISRS = Adult ADHD Investigator Symptom Report Scale

ASRS = Adult ADHD Self-Report Scale

BADDS = Brown Attention Deficit Disorder Scale

CAARS = Conners Adult ADHD Rating Scale

References

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