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Commentary

Culturally Competent Strategies for Assessing and Treating ADHD in African American Adults

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder associated with symptoms of inattention, hyperactivity, and impulsivity.1 When ADHD persists into adulthood, patients often experience occupational and social impairments and may present with mood, anxiety, or substance use disorders.2 Despite the deleterious effects of ADHD, many adults, especially minority patients, remain undiagnosed and untreated.3

Converging factors contribute to this problem, including population-specific characteristics such as a lack of knowledge of ADHD and access to care, as well as health care system-related issues such as a lack of culturally competent providers and stereotyping or biases.4 To provide culturally competent care for African American adults with ADHD, clinicians must understand the prevalence of adult ADHD, use a multifaceted diagnostic approach when assessing patients for ADHD, and individualize treatment plans by effectively collaborating with patients and their families.

Prevalence of ADHD in African American Adults

Limited data are available regarding the prevalence of ADHD among African American adults. One study5 of working adults between the ages of 18 and 44 years found that 1.4% of African Americans are estimated to have ADHD. According to another report, an estimated 4.4% of adults in the United States have ADHD, with almost 2% of African American adults having the disorder.6

Due to the lack of research that includes minorities, the African American community is viewed as a uniform group, but, in reality, many different communities exist. Hopefully, future research will provide a more nuanced view of how ADHD affects various groups of African Americans.

Assessment of ADHD in African American Adults

Clinicians should assess for signs or symptoms of ADHD in adults who are facing recurring problems related to job loss, relationships, reckless behavior, or social rejection.7 Many adult patients will not recognize the source of their problems, which is why clinicians should use a multifaceted diagnostic approach to screen for ADHD. Because no single tool or laboratory test currently exists for diagnosing ADHD, formal diagnosis should be made using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM), clinical assessment, rating scales, and, if warranted, neuropsychological tests.

DSM Criteria

While the DSM criteria for ADHD provide the basis for diagnosis, clinicians must understand that its classification system was inherited from the 19th century European model that distinguishes diseases based on unique symptoms, etiology, course, and treatment, which were described using studies conducted mainly on middle-class white subjects.8 Psychiatric disorders, such as ADHD, however, are variably expressed across cultures. Clinicians must understand the magnitude of cultural and racial differences when assessing patients for mental health concerns.9 At the same time, clinicians must avoid stereotyping because the black population is heterogeneous and includes African American, Caribbean, and Hispanic populations.

The DSM-5 suggests that culture-related diagnostic issues may contribute to clinicians’ misjudging the severity of a problem or giving an inaccurate diagnosis.1 Cultural formulation, which is described as a framework for clinical evaluation, can help mitigate diagnostic errors that may occur from clinicians’ assumptions about symptoms, manifestation, expression, and course.1 The DSM-5 provides 2 cultural formulation interviews, which may be administered by clinicians to the patient or an informant.

Clinical Assessment

Clinical assessment should include symptoms, level of impairment, developmental history (including developmental comorbidities), family history, educational history, psychological testing, collateral history, and the individual history, including cultural and contextual factors. In adults, inattention is the predominant symptom, which can include disorganization, unreliability, forgetfulness, inefficiency in planning, inability to complete tasks and trouble with task shifting, and time management issues.1 Hyperactivity may diminish in adults, but symptoms may include moving one’s hands and feet, feeling restless, talking excessively and interrupting others, and having poor impulse control. The patient must have had several inattentive or hyperactive/impulsive symptoms present before age 12 years.1 Symptoms must be present in 2 or more settings (home, school, work, or social events), must interfere with or reduce the quality of functioning, and cannot be explained better by another diagnosis.

Rating Scales and Collateral Reports

Adults with ADHD may have developed coping strategies to compensate for their symptoms, and they may have symptoms that overlap with those of other conditions. Because these factors can hinder recognition of ADHD, clinicians may be assisted by the use of screening and diagnostic instruments designed specifically for adults.2

Several clinician- and self-administered ratings scales are available to aid the assessment of ADHD in adults. These scales supplement the clinical interview but should never replace it.2 One scale is the clinician-administered Conners Adult ADHD Diagnostic Interview, which includes questions regarding both childhood and adulthood ADHD symptoms, with examples, and a brief screen for comorbidities.2 The Adult ADHD Self-Report Scale (ASRS) V1.1 is a screening instrument that assesses the frequency of symptoms.2

In addition to rating scales, diagnosis of ADHD typically requires informant reports.1 For many African Americans, family is their main support system, and including family members in a patient’s assessment and treatment, with the patient’s permission, may be helpful.10 On rating scales, however, patients’ and informants’ feedback is influenced by their own cultural filters and “historical concepts,” or the meaning and interpretation that individuals assign to their histories. Mental health care practitioners regularly obtain a present, past, and family history of illnesses from their patients. Providers must also explore patients’ and families’ historical concepts, as being “history sensitive” is a fundamental way in which providers can reduce African Americans’ cultural mistrust of the mental health care system.

Neuropsychological Tests

Neuropsychological tests may be used to evaluate impairments in attention and executive function, learning, and processing speed.11 Some common neuropsychological tests include the Stroop Color and Word Test, Trail Making Test, and Continuous Performance Test. While these tests can help quantify attentional and cognitive deficits, single test measures do not have adequate diagnostic value in ADHD.12

Treatment of ADHD in African American Adults

Clinicians should work closely with patients and their families to ensure that they avoid a cycle of blame, hopelessness, or self-defeating behaviors. Treatment may include pharmacotherapy, psychotherapy, or both, in addition to using alternative therapies or working with a pastor.

Pharmacotherapy

Pharmacotherapy is typically the first-line treatment for ADHD, but many factors must be taken into consideration when assessing each patient’s case.7 Clinicians must recognize that, in general, African Americans have low utilization of stimulants, which may stem from mistrust or fear of addiction.13 Stimulants that are adequately dosed for adults improve symptoms in about 70% of patients.7 However, due to their potential for abuse or diversion, stimulants should not be prescribed for patients with current substance abuse or who may sell the drug.7 Nonstimulant medications or antidepressants may be used for patients who cannot tolerate or are resistant to stimulants.7 Medical history should also be considered.

Psychotherapy

For African American adults with ADHD who cannot or will not take medication, other treatment approaches are necessary. Psychotherapy may be used to help patients cope with problems related to sustained attention, inhibitory control, working memory, and motivation, problems that may contribute to the core ADHD symptoms of inattention, hyperactivity, and impulsivity.14 Cognitive interventions may also target negative thought patterns and emotions that lead to patients’ continued failure and underachievement.14

Examples of psychotherapy include cognitive-behavioral therapy (CBT), mindfulness meditation training, and group metacognitive therapy. A review14 of CBT for adults with ADHD revealed that repetition and reinforcement of targeted compensatory skills for core symptoms were key elements of successful therapy versus interventions that covered too wide a range of topics. In addition, CBT combined with medication has proved effective for reducing ADHD symptoms, depression, and anxiety in patients with residual symptoms.15 As an adjunct to pharmacotherapy, psychosocial therapy can help patients with ADHD improve functional performance and maximize benefits from medication.16 A pilot study17 demonstrated that both CBT with placebo and CBT with medication improved core ADHD symptoms and functioning, with no significant differences between the groups (Figure 1).17 This study suggests that CBT alone can be as effective as CBT with medication for adults with ADHD.

A culturally congruent model of therapy for African Americans is the Intersystem model, which is an integrated and comprehensive model that assimilates properties from not only the individual but also interactional and intergenerational patient systems.18 This model offers a contextual framework to help assess and treat many complex problems that arise from ADHD. One of the many strengths of the Intersystem model is that it recognizes the complexity of the person’s life, relationships, and problems and supports these multiple viewpoints.

During treatment, therapists must confront any stereotypes they have regarding African Americans. This process should be done before and throughout the relationship with patients.19 The patient’s race is critical, and conversation about it should not be avoided because what is unsaid can seep into other areas of the relationship between patient and therapist. Furthermore, therapists should be cognizant of the patient’s needs and should discuss the patient’s expectations of the therapy and its course.

Throughout treatment, therapists should focus on patients’ strengths, such as resilience and optimism, and social supports, including friends and family. Given the importance of family, the use of multiple family groups can be effective in treatment for African Americans affected by ADHD. Different family members may come together with other families to learn and support one another. Clinicians should also be sensitive to gender alliance, as well as draw on the individual’s religion if that may be beneficial.

Strategies to Promote Culturally Competent Care

Culturally competent care involves the delivery of mental health services that are respectful of and responsive to the health beliefs, practices, and needs of African American patients.20 Cultural competence has a positive effect on patient care and is a critical element in reducing health disparities and improving access to high-quality care.20

One way to improve cultural competence is for clinicians to learn to recognize and manage biases. Clinicians should consider 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-based 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 appears 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.

CONCLUSION

ADHD causes significant functional impairment in adults if left undiagnosed and untreated. More research is needed to clarify the prevalence and effects of ADHD in African American groups. African American adults may not recognize their symptoms due to a lack of knowledge or because they have developed coping strategies. Clinicians should use a multifaceted diagnostic approach when assessing adult patients for ADHD. This approach should incorporate DSM criteria, a thorough clinical interview, and rating scales such as the ASRS. Comorbid conditions must also be confirmed or ruled out, as many conditions have overlapping symptoms with ADHD. Treatment for ADHD includes stimulant and nonstimulant medications, psychotherapy, or a combination of the two. Clinicians who take the time to listen and understand their African American patients’ background, beliefs, and concerns will be able to alleviate patients’ feelings of fear or mistrust. Clinicians must recognize and remove bias and look for ways to educate patients, their families, and communities regarding mental health disorders and their treatment. With a focus on culturally competent care, clinicians can better assess and treat their patients with ADHD, leading to improved symptoms and quality of life.

Drug name: dextroamphetamine (Dexedrine and others).

Disclosure of off-label usage: Dr Rostain has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration-approved labeling has been presented in this activity.

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