The impact of culture on ADHD

Key Points

You've probably had this conversation. The one in where you tell your patient and their parents that attention-deficit hyperactivity disorder (ADHD) is the cause of the problem. With a diagnosis at hand, you begin to explain the behavioral and/or pharmacological interventions to parent and child. They are unsettled and concerned, a common reaction. But perhaps something else is driving their response-their cultural background.

It's a variable that many pediatricians may not consider, but ethnicity/race can influence how a patient and their family respond to a diagnosis of ADHD and its subsequent treatments. Research into the issue of ADHD and culture shows that differences in incidence rates have not been reported consistently among various ethnic groups or races, although minority children may be at a higher risk for a diagnosis of ADHD than their white counterparts.¹ The use of medications to treat ADHD, however, is lower among certain minority groups compared with whites. One study, using data from the National Health Interview Survey, found that fewer Hispanic (48%) and African American (49%) children with ADHD used medication compared with white (61%) children.² Those findings were similar to data from an earlier study, which found that stimulant medications were more commonly prescribed in white patients compared with other races.³ A possible explanation for the disparities in prescribing patterns was thought to be related to cultural bias.³

Given this finding, it may be helpful to understand some of the reported cultural attitudes or beliefs that may have an impact on a diagnosis of ADHD or affect treatment-seeking behaviors. Although a detailed review of various ethnic groups is beyond the scope of this article, a brief synopsis for several groups follows.

Hispanic heritage

The Hispanic population is currently the largest minority group in the US. This group faces many challenges that may impede the diagnosis or treatment of ADHD, including a greater stigma regarding mental disorders, and less frequent use of mental health specialists.

Specific behavior patterns may also place these patients at risk for over-diagnosis. For example, members of the Hispanic culture have been reported to organize activities in a circular fashion, doing many things in one unit of time (polychronic culture); whereas European Americans organize activities linearly, sequentially doing one thing at a time (monochronic culture). Furthermore, schedules and punctuality are unimportant to polychronic cultures, whereas lateness or interruptions are not tolerated in monochronic cultures. As a result, Hispanic children may be at a greater risk of being identified as impulsive or inattentive when they exhibit what appears to be off-task behavior while acting in a polychronic manner.

Certain Hispanic groups may believe there is a lack of efficacy among available treatments. Selected patients from Colombia, the Dominican Republic, and Guatemala have reported a preference for a natural or holistic approach to treatment over the use of conventional prescription drugs.⁵ In addition, although folk medicine ("curanderismo") is no longer practiced by more acculturated Mexican-Americans, those with less acculturation may still prefer self-treatment or folk healing over Western medicine.⁶

African American heritage

Unfortunately, few ADHD studies contain an adequate number of African American patients. Among African American patients, there is a perception of a disproportionate rate of ADHD prescriptions.⁷ A need also exists for increased education about ADHD. A study of elementary school children (n=182) found significant differences be tween African American and Caucasian families with regard to the definition of ADHD, the causes of ADHD, the most worrisome consequences of ADHD, and the preferred treatments for ADHD.⁸