There is no single African-American experience. Consider three different 8-year-old African-American boys, one each from the Mississippi delta, Chicago’s inner city and Prince George’s county’s affluent suburbs. Their cultures will have significant differences, and a cookbook cultural competency model would not serve them well. While consideration of these issues regarding ADHD in African-Americans is helpful, cultural humility is a must within each individual patient encounter. Cultural competency implies an endpoint; however, cultural humility embraces a lifelong process that includes self-reflection, introspection, advocacy, and co-learning.
ADHD is a common and treatable disorder that can have significant implications for social, educational, and occupational trajectories. Diagnosis rates have increased over time. Based on parent report data from the National Survey of Children’s Health, 2011 to 2013, the percentage of youth aged 4 to 17 years with a diagnosis of ADHD increased significantly from 7.0% to 10.2% overall and from 5.5 % to 9.6% in non-Hispanic black children.1
Diagnosis, assessment, and barriers
On one hand, while early identification is the goal, ADHD’s prevalence can lead to over-diagnosis with less emphasis on co-occurring disorders. All that fidgets is not ADHD. This may be particularly relevant in black populations. Multiple environmental and psychosocial issues that disproportionately affect African-American youth may consequently manifest in symptoms that overlap with those of ADHD. On the other hand, African-Americans in general are disproportionately affected by structural barriers to care as well as by stigma regarding mental illness. These factors can lead to underdiagnosis or delays in diagnosis.
Trauma can affect attention, concentration, and impulsivity. The Adverse Childhood Experiences (ACEs) studies revealed that the incidence of childhood exposures to two or more adverse experiences was higher in blacks than Hispanics or whites. Although the higher the income, the lower the trauma load overall, this relationship was less pronounced for blacks. In other words, income did not appear to be a protective factor. In fact, middle-income blacks had a higher percentage of two or more ACEs than middle class or nearly poor whites.2
Asking directly about traumatic exposures is an absolute necessity in working with black youth and families. While trauma-related diagnoses are by no means mutually exclusive with ADHD, if both are present, it is imperative that the family is educated about the psychological impact of trauma and that treatment interventions target both issues.
Dr Mattox is Professor and Chair, Dr Vinson is Associate Professor, Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta, GA.
The authors report no conflicts of interest concerning the subject matter of this article.
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