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Minority youth make about half as many mental health visits as white children, according to a 2016 study by Lyndonna Marrast, MD, and colleagues. They found that among African Americans, children saw mental health professionals 47 percent less and young adults 68 percent less compared to whites. Among Hispanics, children’s visits to mental health professionals were 58 percent less and young adults were 62 percent less compared to whites. The researchers note “psychiatric and behavioral problems among minority youth often result in school punishment or incarceration, but rarely mental health care.”

Causes of disparity

The Marrast study controlled for demographics, mental health impairment, insurance status, and poverty in its analysis, and found those factors did not diminish the racial/ethnic disparities in mental health care. 

So what are the root causes of such disparity?

Cultural and contextual factors play a role in the assessment and treatment of ADHD. An understanding of mental health by members of under-represented groups is embedded in their unique ideologies, systems, and practices. 

A recent literature review of research studies by Alaa M. Hamed, MD, MPH, and colleagues, assessed factors that interfere with the diagnosis of ADHD, such as the role of parents, aspects of the medical system, school-based factors, and those inherent to the child. Their findings:

  • Different interpretations or explanations for the symptoms of ADHD exist among different cultural backgrounds.
    • In some cultures, hyperactivity and/or impulsivity in boys can be endorsed as typical by parents and viewed as gender preferred behavior. 
    • In some immigrant communities, a psychiatric diagnosis of ADHD is associated with isolation and social exclusion. 
  • Children from different backgrounds can exhibit symptoms resembling ADHD but have a different origin such as trauma from exposure to violent environments, or a language barrier from recent immigration. Children from homes where English is the primary language were four times more likely to be diagnosed with ADHD than those from non-English homes.
  • Health care professionals need awareness of differing cultural beliefs and belief systems in order to align parental beliefs with clinical psychoeducation and treatment recommendations.
  • Clinical assessments of ADHD often rely on teacher reports of the child’s behavior. However, when the teacher lacks an understanding of cultural differences in ethnic/racial groups, under-reporting or skewed reporting often occurs. 
  • Trust is a crucial factor in whether parents and children can collaborate effectively with caregivers―including healthcare professionals, teachers, and law enforcement. Trust is achieved when communication with caregivers is grounded in understanding and respect, free of bias.

The consequences of disparity

“Untreated ADHD can pose a tremendous amount of psychological, financial, academic, and social burden to the individual and the community,” asserts the Hamed review. The authors cite multiple research studies on the impact of undiagnosed and untreated ADHD in:

  • Academic impairment and underachievement
  • Impairment of social relationships: 
    • Untreated hyperactivity has been linked to long-term social and peer problems 
    • Poor listening skills and poor frustration tolerance can lead to tension at work and home, decreased intimate relationships, internalizing problems, and low self-esteem in adulthood 
    • One study found a connection between childhood ADHD and intimate partner violence in adulthood associated with conduct disorder 
  • Impairment in occupational functioning: 
    • Negative impact on work efficiency leading to longer hours of work, job instability, lack of insight into future goals, and lower annual personal incomes
  • Higher rates of criminality, imprisonment, speeding, traffic violation, and motor vehicle accidents
  • Risk factor for later adult mental health issues:
  • Increased likelihood of developing co-occuring disorders such as anxiety, depression, personality disorders, antisocial behaviors, and substance abuse
Recommendations from research

The Hamed review authors end by saying, “Strong partnerships between clinicians and patients with ADHD may be the best way to reduce the negative impacts of the disorder.”

An analysis of the Hamed review makes the following recommendations in order to achieve that objective in a way that improves outcomes for minority populations:

  • More diverse and inclusive evidence-based research, through culturally responsive investigations using decolonizing, indigenous epistemologies, and research methodologies, in order to benefit ADHD research and produce a more inclusive and representative body of knowledge.
  • Educators and practitioners working with persons affected by ADHD should assess their philosophies of practice and education. Integration of a culturally sensitive awareness of individual biases, with a focus on recognizing that patients from under represented communities may have experienced oppression, discrimination, and bigotry when dealing with mainstream institutions e.g. medicine. 
  • Meaningful partnerships with families and professionals working with and providing care for persons affected by ADHD to support social justice efforts that encourage access to culturally relevant services and shared decision-making among various ADHD stakeholders.

This article appeared in ADHD Weekly on July 20, 2017.

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