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CME Objective

After studying this article, you should be able to:

‘ ¢ Choose an appropriate strategy for approaching a Hispanic patient with ADHD about his or her diagnosis and treatment

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The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note: The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hour of Category I credit for completing this program.

Date of Original Release/Review

This educational activity is eligible for AMA PRA Category 1 Credit™ through February 28, 2017. The latest review of this material was December 2014.

Financial Disclosure

All individuals in a position to influence the content of this activity were asked to complete a statement regarding all relevant personal financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. In the past year, Alan J. Gelenberg, MD, Editor in Chief, has been a consultant for Zynx Health and Bloom Burton, has received grant/research support from Pfizer, and has been a stock shareholder of Healthcare Technology Systems. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure appears with the article.

J Clin Psychiatry 2015;76(2):170-173 (doi:10.4088/JCP.13009co6c)

© Copyright 2015 Physicians Postgraduate Press, Inc.

This Commentary section of The Journal of Clinical Psychiatry presents the highlights of the planning teleconference series “Challenges in the Recognition and Management of ADHD in Hispanic Adults in the United States,” which was held in April and May 2014. This report was prepared and independently developed by the CME Institute of Physicians Postgraduate Press, Inc., and was supported by an educational grant from Shire.

The teleconference was chaired by Anthony L. Rostain, MD, Department of Psychiatry and Pediatrics and the Adult Developmental Disorders Section, University of Pennsylvania Perelman School of Medicine, Philadelphia. The faculty were Yamalis Diaz, PhD, Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York; and Juan Pedraza, MD, Department of Psychiatry, Mount Sinai School of Medicine, New York, New York.

Financial disclosure: Dr Rostain is a consultant for Biobehavioral Diagnostics, Pearson, Alcobra, and Shire; has received grant/research support from AHRQ and SUNY Upstate; is a member of the speakers/advisory boards for Biobehavioral Diagnostics and Pearson; and has received royalties from Routledge/Taylor & Francis. Drs Diaz and Pedraza have no personal affiliations or financial relationships with any commercial interest to disclose relative to the activity.

The opinions expressed herein are those of the faculty and do not necessarily reflect the opinions of the CME provider and publisher or the commercial supporter.

Hispanic Americans make up the largest minority group in the United States.1 The Hispanic community is heterogeneous, composed of individuals from various regions of Central and South America, Mexico, and the Caribbean Islands, all with different cultures, language proficiency, and economic status.

The Hispanic community in the United States is disproportionately underserved with regard to mental health,2 leaving many adults with undiagnosed and untreated attention-deficit/hyperactivity disorder (ADHD) that can cause strong role impairment.3 Although ADHD is considered a disorder of childhood, for roughly 60% of individuals, symptoms will persist into adulthood.4

Many adults of all ethnic backgrounds with ADHD remain undiagnosed.5 Making a diagnosis of adult ADHD is challenging because patients may not recall information about childhood symptoms, and obtaining collateral information can be especially difficult for individuals who grew up outside the United States. For Hispanic adults, cultural and instrumental barriers that prevent them from accessing care for ADHD include factors ranging from cultural beliefs about mental health to language barriers.6 To help conquer these barriers and provide effective treatment to Hispanic people, clinicians must learn to approach diagnosis and treatment of ADHD in a culturally competent manner.

BARRIERS TO MENTAL HEALTH TREATMENT

Before seeking treatment, patients must recognize that a problem exists,7 but many Hispanic individuals have cultural beliefs and values that do not recognize ADHD symptoms as problematic.6

Cultural Issues and Attitudes

Acculturation level has been found to affect how Hispanic individuals perceive ADHD symptoms, particularly impulsivity and hyperactivity, which are seen as normal behaviors, especially in the children for whom those symptoms most commonly apply.8 Hispanics may also fail to seek treatment because of a general lack of knowledge about mental illness, particularly ADHD.6 Additionally, like the greater population, Hispanics wrestle with the stigma of mental illness,9 but stigma can be compounded by a general distrust and uneasiness regarding mental health providers or doubts about the benefits of treatment.10 Therefore, relying on extended family or community or religious leaders is common for Hispanic individuals who are undergoing a mental health crisis.11

Once an individual does seek treatment, the clinician must be aware of the cultural and social context that may affect manifestation of ADHD.6 Hispanic individuals may also have a reluctance to divulge personal problems that they believe should be kept private or within the family.12 Clinicians, therefore, must be mindful of the level of a patient’s acculturation and sensitive to cultural beliefs that may be deeply rooted.

Shortage of Mental Health Providers

Another barrier to treatment for ADHD is the shortage of mental health providers, especially Hispanic professionals who could bridge cultural and language barriers.12 Mental health providers are especially lacking in rural areas.2

Communication Problems

Perhaps the greatest barrier to service use among Hispanics is language. In an American community survey, about 30% of Spanish-speaking adults reported poor English proficiency (Figure 1).13 Assessment interviews and instruments for ADHD 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.14 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 may not make sense to a Spanish-speaking Hispanic patient.

STEPS TO IMPROVE MENTAL HEALTH CARE

Provide Education

Providing education about mental illness to the community (eg, schools, religious organizations, health care centers) may help to lessen stigma, build trust, and increase treatment-seeking behavior (Table 1).15 Clinicians should work with patients to resolve instrumental obstacles to treatment, such as lack of insurance, language barriers, and transportation or scheduling constraints. For example, for patients without insurance, clinicians could provide information on free or low-cost insurance options or voucher programs that 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.

Establish Rapport

By embracing a positive relationship and rapport with their Hispanic patients,10 clinicians can break down the barriers of mistrust and uneasiness that many of these patients experience when seeking mental health services. 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. This guardedness can be combatted by establishing a schedule of frequent follow-up visits and engaging patients in the treatment process so that they feel more comfortable asking questions and discussing their beliefs. To establish rapport, clinicians must display a sensitivity and responsiveness to the language and diverse histories, traditions, beliefs, and values of Hispanic patients.2

Meet Language Needs

Clinicians may need to study Spanish or work closely with a translator to ensure that they can communicate clearly and accurately with their Hispanic patients. Translators help to overcome the language barrier, but if they neglect or are unable to consider context and meaning when translating, the clinician could still misunderstand the symptoms a patient is reporting, and the patient may misunderstand what the clinician 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. If patients have limited English proficiency, clinicians should provide simple explanations and avoid statements or questions that involve complex ideas that do not translate well or that require nuanced understanding. Educational materials in Spanish should also be available.

• Be aware of the barriers that keep Hispanic patients from seeking mental health care, including lack of knowledge, negative attitudes, and communication problems.
• Build a solid clinician-patient relationship to increase patient trust with Hispanic patients.
• Work with a translator to provide literature and services to patients with low English proficiency.
• Be aware that many symptoms of ADHD may not fully apply or translate well to Hispanic patients.

Use Appropriate Rating Scales

A diagnosis of ADHD in any patient is rendered using a clinical interview and various rating scales.16 Although these scales have been tested in adult populations,17 some may not be effective in Hispanic populations. For example, Gerdes and colleagues14 administered a Spanish version of the Disruptive Behavior Disorders rating scale to Latino mothers to assess for ADHD in their children and found that the hyperactive/impulsive subscale was not culturally appropriate.

Nevertheless, some rating scales are effective in this population. Clinician-administered rating scales, aided by self-report scales, should be used.18 Rating scales such as the Adult ADHD Investigator Symptom Rating Scale (AISRS) and Adult ADHD Clinical Diagnostic Scale (ACDS) facilitate communication between clinicians and patients, which can build rapport, identify any language barriers, and ensure that questions are understood by Hispanic patients.

CULTURALLY COMPETENT TREATMENT

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, acculturation level, immigration status, mental health history, and other factors that make the patient unique. 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 also 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, 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.16,19 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 mistrust, stigma, or lack of insurance. Clinicians should then use this information to provide accessible and effective treatment.

Clinicians must be able to identify and alleviate barriers including a lack of education regarding ADHD, lack of trust in mental health providers, and problems communicating symptoms. By maintaining rapport and working through the language gap by providing Spanish-language materials and working closely with translators, clinicians can begin to remove barriers that prevent patients from seeking mental health care, as well as the barriers that prevent clinicians from providing culturally competent care.

References

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