Diversity Issues and ADHD Shalonda Slater November 5, 2003.

Diversity Issues and ADHD

Shalonda Slater

November 5, 2003

Aspects of Diversity

International issues Ethnically diverse populations Age Gender Socioeconomic status

International Differences

International prevalence rates are somewhat uncertain

Due to differences in: Symptom terminology Diagnostic criteria Treatment modalities

(Gingerich et al.,1998)

International Differences

A study conducted by Mann et al. (1992) compared diagnostic methodology among clinicians in several countries Differences in ratings were significant There were differences in character and

severity of diagnosis

International Differences

Prevalence rates In Canada: 9% for boys, 3.3% for girls In Chinese children, rates range from 1.3% to

13%, 3% met DSM-III criteria In Puerto Rico, rates range from 16.5% to

9.5% 6.9% probable cases in a sample of Italian 4th

graders(Gingerich et al.,1998)

International Differences

Prevalence rates varied cross-culturally with same cutoff was used on Conner’s Teacher Rating Scale 8% in Germany 15% in New Zealand 16% in Spain 12% in Italy

4.5% in Scottland

9% in Hong Kong12% in Austraila5% in Isreal

(Gingerich et al.,1998)

International Differences

More research is needed in this area Under-, over-diagnosis due to diagnostic bias,

misinterpretation of prevalence data, misjudgments of appropriate treatments

Cross-cultural comparisons of ADHD need to be evaluated in the context of the norms and expectations of a culture

Each culture defining its own syndromes (Chandra, 1993)

Cross-cultural treaments

Behavioral Parent Training for Taiwanese parents For treatment of children with ADHD/ODD Addressed social desirable behavior of children with

ADHD In the cultural context of a Confucian society 14 of 23 families completed treatment Completion resulted in the reduction of ADHD/ODD

symptoms(Huang et al., 2003)

Cross-cultural treatments

Conclusions Behavior training is generalizable across cultures Economic status has important implications for

interventions Limitations of the study

39% of families dropped out of the program The interaction between Confucian values and the

Barkley Parent Training Program were not evaluated

(Huang et al., 2003)

Ethnic Groups in the U.S.

Minority status has been associated with a higher prevalence of ADHD and greater severity of symptoms

Differences in prevalence and severity may be due to: Variations in assessment instruments Differences in diagnostic strategies True differences in frequency of ADHD

(Gingerich et al.,1998)

Ethnic Groups within the U.S.

Studies in the 1970’s compared African American, Latino, and Asian American children to established White norms African American children rated as more

hyperactive than expected Latino children as hyperactive as expected Asian American children less than expected

(Gingerich et al.,1998)

Cultural sensitivity of diagnostic tools

ADHD Rating Scale-IV School Version Assessed the validity with African American and

Caucasian boys Teachers rated African American boys higher on

all scales The scale did not perform similarly across groups There was a different relation between items

across groups(Reid et al., 1998)

Cultural sensitivity of diagnostic tools

Conner’s Abbreviated Teacher Rating Scale Compared teacher ratings of Hispanic and non-

Hispanic children Children were rated similarly on subscales of

ADHD symptomatology Hispanic and Caucasian children were rated

similarly on overall measures of behavior problems

(Ramirez et al., 1998)

Maternal ratings of behavior

Maternal ratings of child ADHD symptoms was significantly correlated with acculturation in Mexican, Mexican American, and Puerto Rican mothers

This relationship was specific to hyperactive symptoms not those of inattention

(Schmitz et al., 1998)

Knowledge about ADHD

Compared the perceptions about medication treatment between White and nonwhite parents Nonwhite parents were more likely to believe that diet

and sugar intake influence hyperactive behavior Nonwhite parents were more likely to believe that

counseling is the best treatment for ADHD Equal proportions of White and nonwhite parents

believed that medication is over prescribed for ADHD

(Dosreis et al., 2003)

Knowledge about ADHD

A study by Bussing et al. (1998) compared knowledge and information about ADHD between African-American and White parents whose child was at risk for ADHD

Face-to-face interviews were done addressing parents explanatory models of ADHD

Fewer African-American parents had ever heard of ADHD,

African-American parents were less likely to attribute ADHD to genetics, they were more likely to label their child as “bad”

Knowledge about ADHD

Over half of parents in study cited doctors as the most common source of information about ADHD

Physicians ranked as the most preferred sources of information about ADHD followed by the library, then mental health professionals

Lower SES parents had lower knowledge scores After controlling for SES, African American

parents had significantly lower knowledge scores(Bussing et al., 1998)

What accounts for differences in knowledge about ADHD?

Why are there “alternative interpretations of illness”? Initial medical advice comes from more informal networks Symptomatic behaviors may be perceived by African

Americans as normal and not in need of professional intervention

ADHD may be viewed by African Americans as a way to target their children for discriminatory practices

ADHD may rank low compared to other competing needs and concerns

(Bussing et al., 1998)

Structure of symptoms across cultures

In an evaluation of the factor loading of ADHD symptom categorizations, a two factor solution fit best Ratings of Native American children were compared

to those of non-Native children Results suggest commonalities in symptom

expression across cultures Researchers suggest that culture affects aspects of

the clinical situation (e.g., perceptions, expectations about care, the course, and etiology of the illness)

(Beiser et al., 2003)

Perceptions of symptomatology

Ratings of parents, teachers were influenced by the ethnicity and SES of the child Teacher ratings were more stable Parents were more influenced by ethnicity

than SES School psychologists rated “lower class” boys

as more hyperactive(Stevens, 1981)

Perceptions of symptomatology

A study evaluated the perceptions of health professionals in diagnosing ADHD vs. Autism Participants given two of four possible

vignettes, which were varied by SES and race Vignettes were weighted toward either ADHD

or Autism Vignettes were brief and vague

(Cuccaro et al., 1996)

Perceptions of symptomatology

Participants were asked to give rankings of the most likely diagnosis

Professional perceptions were not influenced by ethnicity

Professional perceptions were influenced by SES Higher SES vignettes had higher rankings of Autism

Professional perceptions differed by discipline(Cuccaro et al., 1996)

Family transmission of ADHD in African Americans Evaluated ADHD in first degree relatives of children with

ADHD and children with ADHD and matched controls Risks were greater in relatives of the children with

ADHD than with controls When culturally sensitive methodology is used,

clinicians can expect a similar expression of symptomatology and familial underpinnings

More research is needed to evaluate the contributions of genetic vs. environmental contributions to familial transmission

(Samuel et al., 1999)

Implications of ethnicity

Clinicians should probe and question their own assumptions to achieve cultural sensitivity

Clinicians should strive for an understanding of the social milieu of their clients before diagnosis or intervention

More research is needed to explore the ways in which culture affects the response of parents and teachers

Age

It is estimated that 30 to 60% of children with continue to meet full criteria in adulthood

Little research has addressed women and ethnic minorities with ADHD in adult populations

(Gingerich et al.,1998)

Age

Hyperactivity poses less of a problem in adulthood

Adults with ADHD have different cultural expectations relative to children Adults are expected to be fully responsible for their

behavior Adults are expected to have self-control Adults are expected to function without constraints

and supervision

Gender

Gender ratio of 6:1 for clinic referred samples Gender ratio of 3:1 for the general population Barkley suggests that its due to referral bias

(1990) A number of researchers hypothesize that boys

are referred much more than girls because the expression of the disorder in boys is more disruptive to parents and teachers

(Gingerich et al.,1998)

Hypotheses about discrepancies in gender ratios

Girls must display more severe behaviors before a referral is made Girls tend to be older when referred, ADHD in girls is

significantly underdiagnosed Females with ADHD have higher rates of depression

than controls Females may be socialized to internalize ADHD

symptoms, while males are socialized to externalize

(Gingerich et al.,1998)

Gender

Most research has utilized White, middle-class, male children as subjects

Some researchers have found few significant differences in the primary ADHD symptoms

Females suffer the same types of disabilities due to ADHD as males

Few intervention studies have included females in the sample

(Gingerich et al.,1998)

NIMH Conference Summary on sex differences in ADHD (1996)

Girls have fewer attention problems and less hyperactivity than boys of a similar age

In at least one study, girls had fewer errors on CPT, and slower reaction times although all studies have not shown such neuropsychological differences

NIMH Conference Summary on sex differences in ADHD (1996)

Higher ratio of males in clinic-referred samples due to higher referral rate for boys because of behavior problems

Clinic-referred females had more severe attentional and intellectual impairment than clinic-referred boys with ADHD

A higher proportion of ADHD office visits after age 17 are by females

No differential sex effect was noted for drugs commonly used to treat ADHD

ADHD in preadolescent girls

Examined the motor functions, executive functioning, and language processing in 93 girls with ADHD, combined type and 47 inattentive type, and 88 matched controls

All ten neuropsychological variables show subgroup differences

Discriminant function revealed high sensitivity but moderate specificity

(Hinshaw et al., 2002)

Socioeconomic Status

Many researchers have found a link between SES and ADHD

A more complex interaction of SES and other factors seems to have the biggest impact on the occurrence of ADHD

(Gingerich et al.,1998)

Socioeconomic status

Ethnic minority status and low SES commonly interact Higher levels of stress lead to higher levels of

pathology including ADHD Barkley’s “social drift theory”

More individuals with ADHD inhabit low SES brackets and increase the inheritability of the disorder

(Gingerich et al.,1998)

Socioeconomic status

Low SES has also been associated with less utilization of health care services, lower incidence of prenatal care, and higher incidence of substance abuse

No causal links have been found between these variables and ADHD

Individuals from low SES background have been found to be less compliant with treatment Less compliant with medication than with

psychotherapy