An 8 year old named Harry is accompanied by his mother to the primary care pediatric clinic. His mother relates that Harry's school wants him on a medication because he cannot sit still. He is always bothering other children in his classroom. There are 30 other children in his class. There is another boy Joel who has similar problems and is on methylphenidate (Ritalin), and is doing much better in not bothering others. Joel is now able to concentrate on his work. Harry's mother believes that Harry is quite bright but he is not learning well in his classroom. He is about to flunk math, reading and science - although he particularly likes science. His teacher says that he is well versed in identifying animals, which is part of the curriculum for his class, and he is much better than most of his classmates in doing so. However, he cannot work in a group, which is part of the science activities, without upsetting other members. He has impulsivity in working with materials and disrupts others who are trying to stay on task. Harry relates that he feels that everyone is out to get him, and that he gets teased about the teacher's frequent admonishments over his behavior. He often has to sit in a chair separated from other children. Harry's mother relates that his behavior was like this in earlier grade levels.
He is quite impulsive at home, often breaking things such as the computer and his toys. He also has broken his right tibia after riding his bicycle off the roof. He cannot sit still at meals. His mother relates that Harry's father has similar traits of being reckless, and inattentive. She relates that Harry's father is against medication for Harry. By his mother's report, Harry's father feels that he is quite successful, even after his own behavioral troubles in school during his childhood. His parents are happily married and his mother cannot think of any major social stressors other than Harry's behavior at this time.
His past medical history is unremarkable. His developmental milestones were all on time prior to age five.
Exam: VS T 37.2, P 105, R 16, BP 90/43. Height and weight are at the 20%ile. Head circumference is near the mean for age. He is happy and active, exploring the office, touching all medical instruments. He speaks coherently and in context, seems sad and then mad when talking about school. He draws a picture of three figures when asked to draw a picture of his family doing something. They are all swimming in the ocean. By Goodenough-Harris scoring, his figures in the drawing are at a 9 year old level. He has no dysmorphic features. His head, eyes, ears, mouth, dentition and neck are normal. His heart, lungs and abdomen are normal. No facial asymmetry or tics are observed. He moves all extremities well. He walks and runs well. He has good muscle tone and strength, without contractures or tremors. His DTRs are 2+/4 for knees, ankles and biceps. He has no rash and no neurocutaneous lesions. His hearing and vision screens were found to be normal.
Harry is evaluated using a variety of methods looking into several domains of his life. Behavioral rating scales (the 1997 revision of the Conners Rating Scale) shows Harry to be above two standard deviations in Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms for both the Teacher and the Parent scales. A school psychoeducational assessment shows Harry to be above average in both performance and verbal IQs, although the examiner did relate that it was difficult to keep him focused on the tasks presented. He is at the 2nd grade level for his reading and writing, but the 3rd grade level for his math and listening comprehension achievement tests.
A behavioral management program is started at his school. He is given preferential seating and he has a rewards/consequences system for keeping on task or if bothering others. He is tried on psychostimulant medication with some loss of appetite. With titrating of the dose, he is found to be much less distracted in school, and he pays much better attention to class activities. A counselor helps Harry learn how to maintain group activities without the other children becoming mad, and gives Harry insight into following rules on the playing field. He is eventually placed in a "gifted and talented" program at his school because of the excellence of his schoolwork and achievements. Medication holidays help maintain his growth.
Attention-Deficit/Hyperactivity Disorder (ADHD) and its treatment have been controversial areas in the US. Because of the number of children thought to have this condition and the number of prescriptions written for this diagnosis, alarmed families and civic groups have wondered if this condition is overdiagnosed. They also worry that medications are overly used and that medications for this condition will be abused or lead to future drug abuse.
However, without diagnosis and treatment, these children face school failure, poor self esteem, drug abuse (ironically), and multiple other problems. The astute clinician understands family and societal concerns, the natural history of the condition, diagnostic tools, and important treatment modalities in order to prevent or ameliorate major problems.
It has been estimated that 3% to 7% of school age children have ADHD (1). Currently, ADHD is the most common neurodevelopmental disorder of childhood (2). With such numbers of children affected, pediatricians and other primary care providers have an important role in assessing and managing many of these children. There are not enough neurologists, psychiatrists, psychologists or similar subspecialists for all children thought to be affected. Boys are diagnosed at least three times as often as girls (3).
Diagnostic criteria can be found in the DSM-IV-TR version of the Diagnostic and Statistical Manual of Mental Disorders (1). Unfortunately, labels and criteria have changed over the years, causing some confusion among practitioners and research groups (4). Previous diagnostic labels have included Minimal Brain Dysfunction (MBD) and Attention Deficit Disorder (ADD). Physicians in Europe and other countries use the term Hyperkinetic Disorder (HKD).
However, it is clear that whatever term is used, this is a clinical diagnosis based on a history of symptoms in multiple environmental contexts observed over time. The core areas that need to be delineated are inattention, hyperactivity and impulsivity. DSM-IV-TR relate three subtypes: 1) a predominantly inattentive type, 2) a predominantly hyperactive-impulsive type, and 3) a combined type. DSM-IV-TR criteria also include the stipulation that some symptoms that caused impairment were present before 7 years of age. Impairment has to be in two or more settings (for instance home AND school), and there must be clear evidence of significant impairment in functioning in interrelationships, schoolwork or in job performance (1). Interestingly, if impairment in school performance and behavioral functioning are not used as part of the criteria, the ADHD prevalence is much higher - 16.1% without impairment criteria versus 6.8% with this criteria (5).
There is also a category in DSM-IV-TR for ADHD, NOS (not otherwise specified) that can be used for children and adults that do not meet criteria for the above mentioned subtypes but have significant impairment from such symptoms. Primary care providers still need to help families and schools with children who do not meet full DSM-IV-TR criteria but have characteristics that cause impairment.
Usually the diagnosis is made in the school age years. High activity levels in toddlers do not invariably lead to ADHD in childhood. Many "hyperactive and inattentive" toddlers end up focusing and engaging in activities without impulsiveness and hyperactivity after maturing through their preschool and early school years. However, one study showed about 1/2 of children thought to have ADHD in their preschool years had a clear diagnosis by age 9 years. These children had more severe symptoms in their preschool years overall compared to peers (6). Therefore, a clinician needs to take great care to understand the ramifications of the child's age but still consider ADHD at these younger ages.
Much discussion has ensued on whether children with ADHD are just part of the normal continuum of children with varied levels of attention, activity and impulsivity. There is no firm evidence that shows a bimodal distribution where children with ADHD are clearly separate in a different part of the continuum. A recent National Institutes of Health report likens ADHD to essential hypertension or hyperlipidemia which are continuous throughout (and not bimodal) in a population, and where the importance of diagnosis and treatment has been shown (7).
The cause of ADHD is still being elucidated. Brain imaging studies (including MRI, PET and SPECT) show differences compared to healthy controls (8). There is a significant genetic inheritance component. Studies have started to implicate genes for dopamine in ADHD. This correlates with the fact that medications clinically helpful for ADHD involve dopamine transmission. Also, imaging studies have shown the frontostriatal regions of the brain to be important, which are rich in dopamine related neurons. Lastly, mice with impaired dopamine transport mechanisms, are hyperactive and resistant to medications (9).
Once diagnosed, ADHD appears to continue into the teen years for about 3/4 of the diagnosed pre-teen school aged children. Untreated, they often have more severe problems with their peers and family. Problems are worsened because of the multiple previous experiences of failing in endeavors, and also the bad relationship patterns that have been built up with family members (10). One half will have oppositional defiant disorder (ODD), conduct disorder (CD), or another psychiatric diagnosis in their teen years. Also, 1/4 will have comorbid learning disabilities (LD), which can be seen in a discrepancy between their scores in tests of learning ability as compared with achievement.
Interviewing the child and family is of utmost importance. Detailed history gathering will reveal the child's characteristics. Also the history should reveal whether the child's problem is in single vs. multiple settings, and how long symptoms have been noted over time. One needs to be careful not to use the child's appearance in the clinic visit as a measure of the child's problems. Children with (and without) ADHD often look different in structured, supervised, and/or novel settings such as a doctor's exam room. Although some children will show inattentiveness and hyperactivity in the clinic office, some children with severe ADHD may look fine in this setting (8).
Tools that can help in the diagnosis of ADHD include parent-child structured interviews which psychologists and psychiatrists are often familiar with, and ADHD behavioral rating scales which most child professionals have some familiarity with. Barkley, in his well known handbook for assessment and treatment of ADHD has detailed chapters regarding these (11). He finds that ADHD specific behavioral rating scales can be useful for a diagnostic assessment of a child or adolescent. Other reasons for using behavioral rating scales include evaluation of response to medication or child response to parent training in behavioral management. An analysis has shown the use of more global behavioral rating scales to not as effectively detect ADHD compared to ADHD specific scales (2).
After this careful information gathering, a clinician needs to decide if a particular child meets criteria for ADHD and whether an alternative diagnosis is primary. Other disorders that can affect attention include anxiety disorders, mood disorders, substance abuse, and schizophrenia. Head injury, seizure disorders, and brain infections can lead to symptoms of ADHD (8). Although hypothyroidism, fragile X syndrome, glucose-6-phosphate dehydrogenase deficiency and phenylketonuria have all been associated with ADHD, testing for these conditions have very low yields and are not suggested unless the history or physical suggests these in other ways (8). Also electroencephalograms (EEGs) and computerized Continuous Performance Tests (CPTs) have not shown sufficient consistent discrimination between children with and without ADHD (2). Children with lead toxicity as toddlers or preschoolers show normal lead levels by the time they are tested in the school age years. Therefore lead screening is also not recommended on a routine basis (2).
The conditions that are most commonly confused with ADHD are mood disorders and anxiety disorders (8). Both of these disorders are often episodic (and not continuous and unremitting like ADHD), with a later age onset compared to ADHD. Some clinicians like to treat the mood or anxiety disorder first, if one of these are suspected, and see if the symptoms of ADHD resolve.
Comorbid conditions that are often found in combination with ADHD include ODD, CD, LD, Tourette's disorder and speech/language disabilities. All of these may also be disorders that may mimic ADHD in some ways (for example a child who appears inattentive because of language processing disorders) but have substantial differences in criteria from ADHD.
Treatment of ADHD requires understanding of four aspects delineated in a recent American Academy of Pediatrics guideline (12):
1) ADHD is a chronic condition. Physicians should be working with families and schools over the long term to help support these children into adulthood. Follow-up over years is required. Initially the clinician needs to inform the family about ADHD. Then this provider will need to work with the family in coordinating other professionals as necessary, involve the family in treating the child and debriefing the situation, and connect the family to support groups as they desire.
2) Target symptoms need to be addressed. Physicians need to negotiate with the child's family and school over which target symptoms will be addressed at any particular time. These target symptoms should have the potential of being improved upon with appropriate support. These also need to be explicit and measurable. An example of a poor target would be to request the child to be a "good" child. More appropriate targets would include: a) Improvement of the relationships with people the child interacts with; b) Abating behaviors that interfere with the activities of others; c) Working on schoolwork being completed with improved accuracy and decreasing the time necessary for completion; d) Being able to work without supervision in schoolwork, homework and activities of daily living; e) Having better self esteem; and f) Improving safety skills.
3) Medication and behavior strategies are important. Many parents want to use only behavioral strategies rather than medication. Interestingly, the American Academy of Pediatrics' review that examined different treatments of ADHD rated medication as "good" and behavioral strategies as "fair" in strength of evidence. This was particularly affected by the Multimodal Treatment of children with ADHD (MTA) study (13). This study randomized 579 children with ADHD from ages 7 to almost 10 years of age to different groups: medication management alone, medication and behavior management, behavior management alone, and a standard community care group. Both groups that involved medication showed a substantial decrease in important ADHD symptoms over a 14 month period. The combined treatment group showed improved academic measures, measures of conduct, and some specific ADHD symptoms (although not on global ADHD symptom scales) compared to the single treatment groups. In reviewing most of the studies comparing behavior therapy with stimulants alone, there seems to be a much stronger effect from stimulants than with behavior therapy (9).
Medications used in ADHD include stimulants such as methylphenidate and dextroamphetamine; antidepressants such as imipramine and desipramine; and alpha-adrenergics such as clonidine. One of the stimulants, pemoline, was more widely used in the past but this has been advised against because of toxic hepatitis and acute hepatic failure (about 4 to 17 times the expected rate). Monitoring liver function tests usually does not alert the practitioner quickly enough to prevent the rapid progression of liver failure. The other more widely used stimulants have no such liver toxicity. Methylphenidate and dextroamphetamine have side effects such as appetite suppression (about 80%) and insomnia. Overall either of these two medications may cause short term slowing of weight gain and growth but long term effects are minimal. Tics may be precipitated in those predisposed to them, with improvement often seen while on drug holidays (9). A new non-stimulant medication, atomoxetine (Strattera) is now an available treatment option.
Stimulant medications show quick and often dramatic results in the ADHD characteristics of children. Unfortunately children without ADHD have similar behavioral responses so the response from medication should not be used as a diagnostic trial. Interestingly, good behavioral effects have been repeatedly shown but long term academic effects have not been shown in any long term trial yet. Antidepressants have also shown good initial efficacy but not sustained effects compared to stimulants. These medications are usually reserved for those with coexisting disorders (such as depression and tics) since they have a higher risk of sudden death which cannot be predicted with plasma drug levels or electrocardiography. Clonidine has also led to sudden death when used in combination with methylphenidate. This medication has a patch form that some families prefer. Serotonin-reuptake inhibitors have no evidence based effects that have been shown (9). Newer delivery systems for more sustained release of stimulant medication (such as Concerta, a time released form of methylphenidate) show great promise. They enable a dose prior to school that lasts 12 to 14 hours, rather than requiring the child to go to the school nurse to obtain another dose after the 4 to 5 hour duration of a short acting stimulant (14).
Behavioral Strategies for children with ADHD include: a) Positive reinforcement (providing desired reinforcers contingent on the child's behavior and activity); b) Time-out (using ignoring and isolation away from desired activity); c) Response cost (taking away rewards or privileges if undesired activity takes place); and d) Token economy (a form of positive reinforcement where the child obtains "tokens" such as stars that can be collected towards a even more strongly desired reward) (12).
4) Close follow-up of target symptoms and medication use. Reevaluation of whether the child has ADHD, a comorbid diagnosis, or another diagnosis altogether is important. Target symptoms should be measured by multiple methods if possible and treatment modified as necessary. These reevaluations and monitoring should be done periodically and consistently. The frequency of followup would depend of the severity of ADHD, other important comorbid conditions or factors, and the effects and complications of treatment.
In the past it was thought that most children with ADHD would have most of these symptoms abate when they become adults (after a rocky adolescence as mentioned above). It is known that many still have the characteristics for the criteria of ADHD in adulthood, and many have significant problems in work, school or other environments (3). Because of the genetic predisposition, many of the parents of the children seen for ADHD will also have ADHD. This complicates management since parents are essential for the child with ADHD to administer medication, and to ensure behavioral follow-through and academic planning.
1. True/False: A child psychiatrist is necessary to diagnose and manage children with ADHD
2. The different subtypes of ADHD in DSM-IV-TR relate to criteria around (select all that apply:)
. . . . a. Inattention
. . . . b. Particular learning disability
. . . . c. Impulsivity
. . . . d. Hyperactivity
. . . . e. Gender
3. Evidence is accumulating that shows ADHD to be connected to (select one):
. . . . a. Serotonin
. . . . b. Mast cells
. . . . c. Cortical sleep centers
. . . . d. Dopamine
. . . . e. Mental retardation
4. Which is the LEAST important concern in managing children with ADHD? (select one):
. . . . a. Parents of children with ADHD may have ADHD themselves.
. . . . b. Target symptoms need to be addressed.
. . . . c. The teen years.
. . . . d. Side effects from Pemoline use.
. . . . e. Growth problems from psychostimulant use.
5. Which should be used routinely in the evaluation of school aged children with ADHD? (select one):
. . . . a. Lead screening.
. . . . b. Electroencephalograms (EEGs).
. . . . c. ADHD specific behavioral rating scales.
. . . . d. Fragile X chromosomal testing.
. . . . e. Parent depression inventory.
6. Which is a common comorbid condition with ADHD?
. . . . a. Learning Disability
. . . . b. Autism
. . . . c. Obsessive Compulsive Disorder
. . . . d. Diarrhea
. . . . e. Seizure disorder
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 2000, Washington DC: American Psychiatric Association.
2. Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, American Academy of Pediatrics. Clinical practice guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics 2000;105(5):1158-1170.
3. Barkley RA. Attention-Deficit Hyperactivity Disorder. Scientific American September 1998;273:66-71.
4. Swanson JM, Sergeant JA, Taylor E, Sonuga-Barke EJS, Jensen PS, Cantwell DP. Attention-deficit hyperactivity disorder and hyperkinetic disorder. Lancet 1998;351:42933.
5. Agency for Health Care Policy and Research. Diagnosis of attention-deficit/hyperactivity disorder. AHCPR Technical Review 1999;3:1-114.
6. Cantwell DP. Attention deficit disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996;35(8):978-987.
7. National Institutes of Health. Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). NIH Consens Statement 1998;16(2):1-37.
8. Zametkin AJ and Ernst M. Problems in the management of attention-deficit-hyperactivity disorder. N Engl J Med 1999;340(1):40-46.
9. Elia JE, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit-hyperactivity disorder. N Engl J Med 1999;340(10):780-788.
10. Schubiner, HH and Robin AL. Attention-deficit/hyperactivity disorder in adolescence. Adolescent Health Update 1998;10(3):1-8.
11. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 1990, New York: Guilford Press.
12. Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, American Academy of Pediatrics. Clinical practice guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108(4):1033-1044.
13. Jensen P, Arnold L, Richters J, et al. 14-month randomized clinical trial of treatment strategies for attention deficit hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073-1086.
14. Wingert P. No more 'afternoon nasties': A new rival of Ritalin keeps kids out of the nurse's office. Time December 4, 2000;p 59.
Answers to questions
1. False, 2.a,c,d, 3.d, 4.e, 5.c, 6.a
Attention-Deficit/Hyperactivity Disorder: Presentation and Management in the Haitian American Child
Nicole Prudent, M.D., M.P.H.,Peggy Johnson, M.D.,Jennifer Carroll, M.D., M.P.H., and Larry Culpepper, M.D., M.P.H.
Dr. Prudent is an Assistant Professor of Pediatrics at Boston University School of Medicine and a pediatrician at Boston Medical Center, Boston, Mass.
Dr. Johnson is an Assistant Professor in the Department of Psychiatry at Boston University School of Medicine and Vice Chair of Psychiatry for Clinical Services at Boston Medical Center, Boston, Mass.
Dr. Carroll is an Assistant Professor in the Department of Family Medicine at the University of Rochester School of Medicine and Dentistry, Rochester, N.Y.
Dr. Culpepper is the Chairman of the Department of Family Medicine at Boston University School of Medicine and Chief of Family Medicine at Boston Medical Center, Boston, Mass.
Author information ►Copyright and License information ►
Copyright © 2005, Physicians Postgraduate Press, Inc.
Prim Care Companion J Clin Psychiatry. 2005; 7(4): 190–197.
This article has been cited by other articles in PMC.
A case study of a young Haitian American is presented that is illustrative of cultural issues that influence care of those with attention-deficit/hyperactivity disorder (ADHD). Medications are the preferred treatment for ADHD and can be combined with psychological intervention. However, many Haitians and Haitian Americans see psychoactive medications as leading to substance abuse or mental illness. Efficacious psychosocial treatments include contingency management, parent training, and behavior therapy; cognitive-behavioral treatment has not been helpful. Complementary and alternative medicine might have appeal; primary care physicians can help families to assess such treatments and not to be enticed by expensive ones of little benefit. A determinant of the treatment a family pursues is their perception of the cause of the ADHD behaviors. While there is no term for ADHD in the Haitian-Creole language, in the Haitian culture the behaviors consistent with the diagnosis might be interpreted as indicating a poorly raised child whose behavior could be modified by parental discipline, an intentionally bad child, or a psychically victimized child suffering from an “unnatural” condition. “Natural” ailments are attributed to natural forces (e.g., wind, temperature), while “unnatural” ones are attributed to bad spirits or punishment by God. Families may “lift their feet” (Leve pye nou: to see a Hougan or voodoo priest) to determine the unnatural cause. Haitian Americans often combine therapeutic foods that are considered cold in nature, natural sedatives and purgatives from herbal medicine, religious treatments, and Western medicine. Immigrants often lack support of extended families in an environment not supportive of their interpretation of child behaviors and traditionally accepted parental disciplinary style. Stigma, language, cultural conceptions, concerns about governmental agencies, and physician bias can all be barriers to care for immigrant families. Primary care and behavioral integration are useful in managing families from other cultures.
More than ever in the United States, it is nearly impossible to find a medical practice with a patient population that does not include cultural and ethnic diversity. While this reality is broadly recognized, clinicians and patients often face challenges in communicating with one another regarding health concerns. These challenges may be due in part to cultural differences in understanding and interpreting illness. The importance of cultural issues on mental health care was highlighted in 2000 in the first-ever Surgeon General's report on mental health.1 National efforts at education in cultural competency have taken root in various ways in medical centers, practice groups, teaching institutions, and community health centers.
Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed chronic mental conditions of childhood. ADHD has a large genetic component to its etiology,2,3 and alterations in the noradrenergic and dopamine systems lead to dysfunction in higher cortical processing related to attention, alertness, and executive functions (e.g., planning, working memory, abstract reasoning, mental flexibility).4
ADHD has been reported in all continents of the world. Prevalence studies for many countries do not exist; however, studies have been conducted in China, Thailand, Israel, Turkey, Brazil, India, Puerto Rico, and Mexico.5 Although the signs and symptoms of ADHD are basically the same in these diverse countries, they each represent a different ethno-socio-cultural context in which the condition is interpreted and responded to by patients, their families, caring professionals, and others.6 Several recent studies demonstrate that in 40% to 70% of children, ADHD persists into adulthood.7,8
Although ADHD has been well established as a condition in children worldwide, the subtler question of how the interpretation of symptoms and behaviors varies between locales remains elusive. Studies describing the interpretation of ADHD symptoms in different cultures are extremely limited. African American parents have been shown to be more unsure of the potential causes and treatments of ADHD and less likely to connect the school system to ADHD issues than white parents.9 In another school-based study, white children with ADHD were twice as likely as African American children to receive evaluation, diagnosis, and treatment, and the threshold of parental recognition and seeking of services contributed to this discrepancy.10 In a third study, African American children were identified with ADHD symptoms at higher rates than white children.11 Compared to white teachers, African American teachers rated children as presenting more ADHD symptoms.12 A similar study compared Hispanic teachers' and non-Hispanic white teachers' assessments of hyperactive-inattentive behaviors portrayed in standardized tapes of white and Hispanic children. Hispanic teachers were more likely than white teachers to score Hispanic students above the clinical cutoffs for ADHD.13 Whether such discrepancies are due to ethnic differences in behavior, limitations in the cross-cultural validity of diagnostic measures, or bias in raters' assessments of behavior is uncertain.
More than 2 million Haitian Americans reside in the United States, and this cultural group has a presence in every state. The following case study of a young Haitian American illustrates the cultural issues that can influence the care of a person with ADHD and the difficulties that can result from culturally based disagreement or inadequate communication between medical professionals, educators, social service personnel, and families.
CASE PRESENTATION: MR. A
Mr. A is a 25-year-old man with a history of ADHD. He was an overactive child from early infancy, and his parents initially attributed his exuberant behavior to the natural tendencies of his sex. Mr. A's parents tried their best to keep his behavior under control by corralling him in his crib, verbally disciplining him, and occasionally spanking him.
From when Mr. A was 3 years of age, his parents became increasingly aware of his hyperactivity, impulsivity, and inability to follow directions. Throughout his pre-school years, he was repeatedly suspended from school and was forced to move from one school to the next. In his community, he developed a reputation for being mal élevé—a French term for “badly reared,” which in turn reflected negatively on his parents within their extended family and community. At age 5, Mr. A was diagnosed by a specialist as having ADHD. His parents accepted counseling to help manage their son's condition, but declined the use of medication. Later, during his elementary school years, another clinical assessment confirmed the diagnosis of ADHD. This time, Mr. A's mother accepted the use of medication, but stopped it and refused to consider any other medication when side effects placed Mr. A into a “zombie-like” state that included sluggishness, difficulty sleeping, and loss of appetite.
When Mr. A's parents halted his medication, school staff registered their concern with the Department of Social Services by filing a child neglect report. Mr. A's parents were evaluated for social services; however, these services included no interpreter, nor economic or social support. His parents were placed on the defensive all the time and began to feel threatened, stating that “the focus was no longer on [Mr. A's] condition, but on our parental abilities.” As a result, to attend to Mr. A and coordinate his care, his mother stopped working outside the home.
Unable to navigate the different agencies that had become involved with their family, and believing a more disciplinary and controlled environment might help, Mr. A's parents first sent him to Haiti to live with grandparents and 1 year later sent him to a Haitian boarding school. Neither environment had an effect on his behavior. Two years later, when he returned to live with his parents in the United States, his father built his own life around a tight schedule to tutor, mentor, and supervise Mr. A's school activities. Mr. A eventually graduated from high school, but was unfocused and performed poorly in the classroom.
After graduation, Mr. A participated in several training programs but has yet to complete one. He continues to be hyperactive and unfocused. At work, he is known as a “good guy” who regularly jumps to defend coworkers, a behavior that often costs him his own employment. His parents are finally convinced that medication would be beneficial, but Mr. A refuses to take medications and denies his disorder.
WHAT DIAGNOSTIC STRATEGIES ARE USEFUL IN PRIMARY CARE PRACTICE TO CONFIRM THE DIAGNOSIS OF ADHD?
Table 1 lists the DSM-IV criteria for the 3 subtypes of ADHD. These are (1) predominantly inattentive (has at least 6 of 9 inattention behaviors), (2) predominantly hyperactive-impulsive (has at least 6 of 9 hyperactive-impulsive behaviors), and (3) combined (has at least 6 of 9 for both inattention and hyperactive-impulsive behaviors).
DSM-IV Diagnostic Criteria for Attention-Deficit/Hyperactivity Disordera
Due to their ability to function with ADHD during adolescence, children with the inattentive subtype of ADHD tend to be the easiest group to manage and are the least likely to have recurring problems; however, they often are the hardest to diagnose. Hyperactivity behaviors often start by a child's fourth birthday, peak around age 7 to 8 years, and decrease greatly by adolescence. Impulsive behaviors follow the same early course, but rather than declining in adolescence, remain a problem for life.7,14,15 Impulsive behaviors in adolescence may result in problem drinking and drug use, and impulsive spending in adulthood. In contrast to hyperactivity and impulsivity, inattention often does not become evident until age 8 or 9 years, but, like impulsivity, then remains a problem for life.
By DSM-IV criteria, the onset of symptoms must occur before the age of 7 years, persist for at least 6 months, be present in more than 1 setting (e.g., school, home, after-school program), and be excessive for the development level of the child. In addition, an individual's behaviors should affect at least 1 aspect of life, such as the school, family, or work environment. As with Mr. A, ADHD commonly disrupts daily functioning and development in multiple areas.
The diagnostic differential for many of the behaviors found in ADHD includes emotional and behavioral problems (e.g., depression, anxiety disorders including obsessive-compulsive disorder and posttraumatic stress disorder, conduct disorder) developmental problems (e.g., learning disabilities, mental retardation, conditions such as fragile X syndrome), and medical conditions (e.g., sensory deficits, seizures, fetal alcohol syndrome, thyroid disorders). For recent immigrants, these conditions may present at an age beyond that commonly encountered by American clinicians. Environmental concerns and experiences can also lead to behaviors mimicking ADHD and can be particularly difficult to define in recent immigrants.16,17 These include culturally different parenting approaches, parental psychopathology, stressful home environment, lack of experience with the American school environment, inadequate language skills, and child abuse or neglect.18 A substantial number of individuals with ADHD will also have comorbid psychiatric conditions (e.g., depression, oppositional defiant disorder, learning disabilities).
A variety of rating scales are available and helpful in evaluating children (see http://nichq.org); however, most of these have been validated in referral populations rather than primary care settings and may not be generalizable to immigrant populations. These scales include ones for use by clinicians, parents, and teachers. Also, collecting information from other settings (e.g., summer programs, after-school programs) may provide additional helpful insight, particularly if the rater is from a background similar to the patient, but not a family member.
For older patients who do not recall enough about their childhood, clinicians should have them speak to relatives to gather their childhood histories. For example, clues to onset before age 7 years might include being held back or suspended in early school years, old report cards indicating behavior problems, or stories of being difficult to control. Scales for adults (e.g., the Wender Utah Rating Scale,19 also available in French20; the Copeland Symptom Checklist for Attention Deficit Disorders21; the Conners Adult ADHD Rating Scale22) can be useful, but yield large numbers of false positives and cannot be relied on for diagnosis without supportive evidence from clinical assessment.23
Treatment approaches to ADHD include an array of psychotropic medications, behavioral and psychological treatments, and complementary and alternative medicine approaches. Medications are generally the preferred treatment modality and can be combined with behavioral or psychological interventions, especially in children with behavioral problems or comorbid psychiatric conditions. Stimulant medications and psychosocial treatment have been the major foci of clinical research; however, the duration of most randomized trials has been 3 months or less, and thus the literature on long-term treatment is sparse. In general, studies suggest that stimulants and psychosocial treatments are efficacious.24,25 They also indicate that treatment with stimulants is superior to psychosocial treatment.26
Short-term trials of stimulants support their efficacy, with response rates in the 70%-to-90% range.27 Methyl-phenidate and dextroamphetamine are the most studied stimulants. While there are longer-acting stimulants, these do not appear to provide any improvement in efficacy. Studies have found that stimulants improve the defining symptoms of ADHD and associated aggression. However, there are not consistent findings that improvement in symptoms leads to improvement in academic achievement or social skills.28,29
Aside from studies suggesting the efficacy of using stimulants, there are also studies of antidepressants showing that tricyclic antidepressants (e.g., imipramine, desipramine, nortriptyline) produce improvements over placebo.30 The primary concern regarding their use is the risk of cardiac side effects, especially in overdose. Atomoxetine also has proven efficacy for ADHD31,32; it is the only medication approved by the U.S. Food and Drug Administration for use in adult ADHD, is not a controlled medication, and might be particularly useful when possible comorbid substance abuse is a concern.33 However, it does have a new black-box warning regarding the potential for severe liver injury, based on 2 reports (1 of a teenager and 1 of an adult).
Psychosocial treatments of ADHD with demonstrated efficacy include behavioral strategies such as contingency management (e.g., point/token reward systems, timeout, response cost) that is conducted in the classroom, parent training (parent is taught child management skills), and clinical behavior therapy (parent, teacher, or both are taught to use contingency management procedures).34 In contrast, cognitive-behavioral treatment (e.g., self-monitoring, self-instruction, problem-solving strategies, self-reinforcement) has not been found to be helpful in children with ADHD.35,36
Complementary and alternative medicine strategies are very commonly used and might have particular appeal to families from other cultures.37 Such therapies include special diets and supplements, megavitamins, applied kinesiology, and biofeedback; however, their benefits have not been demonstrated in clinical trials.38 Diet, including reducing sugar, affects behavior in less than 1% of children.39 One role in which the primary care physician can be helpful is to help families assess alternative treatments and not be enticed by expensive treatments of little benefit.
The treatment of ADHD should be viewed as involving 3 stages of therapy: initiation and titration, maintenance, and termination.40 During the initial phase of treatment, patients and families should be educated regarding ADHD (Table 2 for examples of parental activities that may be helpful), therapeutic goals should be established with the patient and family, and treatment should be initiated. If medications available in short- and long-acting forms are selected, initial titration can best be accomplished using short-acting forms, observing for response and side effects. This can be followed by switching to longer-acting forms if desired. Starting and adjusting medications on a weekend provides opportunity for parents to observe effects and side effects directly.
Parent Activities That Can Help Modify the Behavior of a Child Who Has Attention-Deficit/Hyperactivity Disorder (ADHD)a
During the maintenance phase, ongoing family education, dosage adjustment, and monitoring of growth, efficacy, and side effects are appropriate. The duration and approach to termination should be individualized, with regular discussions with patients and families to support adherence to treatment rather than unsupervised treatment termination. Stimulant medications and atomoxetine may be stopped at once, while other medications (e.g., tricyclic antidepressants) may need to be tapered. Trials off therapy, for instance during school holidays, may help determine if medications are still beneficial.
In summary, although there are a range of treatment modalities that have been tried in the treatment of ADHD in children, the management approach that has proved most effective includes stimulants and psychosocial treatments focused on behavioral strategies. Of note, in one large study funded by the National Institute of Mental Health, there was no difference in response to treatment between ethnic groups (Latino, African American, and white).41
ADHD AND ITS CARE FROM A HAITIAN PERSPECTIVE
While there is no corresponding term for ADHD in the Haitian-Creole language, in the Haitian culture the behaviors consistent with the diagnosis of ADHD might be interpreted as indicating the following:
A “poorly raised child,” whose behavior could easily be modified through parental discipline. This can be stigmatizing within the Haitian community and places parents on the defensive. Mr. A's parents suffered from the reputation of having a mal élevé child.
An “intentionally bad child” who embarrasses his or her parents. Children with ADHD are often compared to “good kids” who are held up to them as examples to follow. This can be a severe insult to both the child's and parents' self-esteem and their sense of self-efficacy.
A “psychically victimized child,” or one suffering from an “unnatural” condition, a curse from a superior force. A religiously influenced family might believe a child is being punished for sins and direct attempts to intervene accordingly.
Among Haitians, the interpretation of ADHD-related behaviors varies widely from family to family depending on religious affiliations, level of education, and experience with school and primary care systems. Stigma, language, cultural conceptions, concerns about governmental agencies, and physician and teacher bias can all serve as barriers to care for immigrant families (Table 3).
Five Barriers to Care for Haitian Immigrants With Attention-Deficit/Hyperactivity Disorder (ADHD)
An important determinant of the treatment or other intervention strategy a family pursues is their perception of the cause of the ADHD behaviors. Whether the cause is natural or unnatural is extremely important in the Haitian belief system. “Natural” ailments are often attributed to natural forces (heat/cold, gas, wind, temperature), while “unnatural” ailments are attributed to bad spirits or punishment inflicted by God. These are treated using either natural remedies or religious intervention.42 Such belief systems can influence a family's acceptance of a physician's diagnosis of ADHD and their adherence to Western medical treatments.
In the United States, as in many other countries, the diagnosis of ADHD is mainly a medical one and involves pediatric and family medicine providers, social workers, and psychologists. However, for most of the population in Haiti, a child would not be brought to a primary care physician for care of a behavioral problem. Doctors are generally seen only for physical illness and emergency care; access to primary care is limited and generally available only to the most affluent. ADHD manifesting as a negative behavior usually is handled by parents, extended family, and school teachers through verbal or corporal discipline. Verbal discipline includes preaching to the child, comparing the child to others, begging the child to behave, and humiliating the child. Corporal discipline and punishment can be inflicted by any member of the family, neighbors, and schoolteachers, all of whom are given full authority to educate and “correct” the child.
Immigration adds a complex dimension to raising children. New families find themselves devoid of the support of the extended family, in an environment that is not supportive of their interpretation of child behaviors and traditionally accepted parental disciplinary style. Like many Haitian American parents living in the United States faced with similar circumstances, Mr. A's parents chose to send him back to Haiti with the hope that a more authoritative parenting style, the enforcement of discipline in school (schoolteachers are very respected), and removal of the interference of the American social worker would offer a better environment for rearing their child. Mr. A went to live with his grandmother first and then off to a boarding school, a setting seen by many Haitian parents as the ultimate answer to a child with behavioral problems.
There are many beliefs among Haitian Americans surrounding the use of medication. Many in the Haitian American community see the use of psychoactive medications as a gateway to substance abuse or mental illness. Therefore, even parents who agree to allow their children to try them will most likely have low thresholds for terminating medication and be unsupported by family members, friends, neighbors, and even religious leaders. Mr. A's parents received much unsolicited advice, and some friends wanted them to “lift their feet” (Leve pye nou: to see a Hougan or voodoo priest) who might be able to determine the unnatural but real cause of their son's problem.
Being transnational and having access to both native Haitian medicine and Western medicine, Haitian Americans routinely combine therapeutic foods that are considered cold in nature, natural sedatives and purgatives from traditional herbal medicine, religious treatments, and Western medicine to treat illness. Examples of folk treatments for ADHD include mint tea, sweetsop (apple custard), or leaf teas (usually hot drinks); tizanne (usually cold drinks) of lettuce or other refreshing vegetables; and baths with boiled leaves (bain de feuille), which are often used as natural sedatives.
While it may be difficult to establish trust with Haitian families initially, such trust in the doctor-patient relationship is essential in obtaining their participation in the development of a treatment plan to which they will adhere. Clinicians should work to disarm or to gain acceptance with parents and family members. It may be helpful to learn a few words of Creole or tidbits of Haitian history, to be respectful of combining benign natural remedies with conventional Western medicine, and to find ways to show respect for the family's heritage. Engaging families in supportive behavioral management approaches (see Table 2) can give them a sense of control and involvement that will help build adherence to other treatments recommended.
Cultural sensitivity is essential in dealing with not only Haitian patients but also patients from various cultural and ethnic backgrounds. One definition of cultural competency is “a set of congruent attitudes, behaviors, and policies that come together in a system, agency, or amongst professionals and enables them to work effectively in cross-cultural situations.”43 Haitians, like most immigrant patients, need sympathetic advice and help from their physicians, as they often feel governmental agencies such as the local department of social services place a great deal of pressure on them to either medicate their children or move their children to other school systems.
In direct contrast, it is also important not to “overemphasize” a patient's culture when considering a diagnosis and treatment. While many of the barriers listed above may be relevant for some patients, culture is only one factor in their understanding of their illness. Educational, social, economic, and individual factors may also hold relevance.
Because the interface of psychiatric disorders—in this case ADHD—and culture is complex, it is a useful context for examining the integration of psychiatric and primary care. While there are a number of models of such primary care and behavioral integration, one, called “primary mental health care,”44–47 is particularly useful in managing families from other cultures. The goal of this approach is to resolve problems within the primary care service context: “primary mental health” is designed to support the ongoing behavioral health interventions of the primary care provider. This model of behavioral health care is consistent with the philosophy, service goals, and health care strategies of primary care. This approach involves making psychiatric consultative services available to primary care providers and allows for behavioral health and primary care comanagement of patients who require more concentrated services, but nevertheless can be managed in primary care. Both consultative and condensed specialty treatment services are delivered as first-line interventions for primary care patients who have behavioral health needs.
In summary, there are several options for assisting Mr. A and his family and other Haitian children and adults with ADHD:
Gain insight into the patient's and family's perception of the problem, its cause, and impact on behavior and function. This often is the starting point for patient education and coming to a shared understanding of the diagnosis and potential interventions.
Develop treatment plans using the family's experiences with helpful and unhelpful strategies as the starting ground. For example, it may be useful to ask the family, “Who (or what agencies) have you found helpful in working with Mr. A? Why?” If the family is unable to name anyone, it may be necessary to broaden the question to “What do you feel you need most in order for Mr. A's functioning to improve?” With this feedback from the patient and parents, it may be possible to revise strategies that have been unhelpful or alienating in the past. Setting appropriate short- and long-term goals for Mr. A is essential to monitor his progress with treatment and behavior.
Support a team-oriented, collaborative approach that incorporates expertise from family and community members, mental health professionals, educators, and other disciplines if necessary, yet anchors the patient's care in a primary care context. In Mr. A's case, there were clearly gaps in communication between the family, school, medical professionals, and social service system, as each worked independently to solve the same problem. Department of Social Services involvement and the attitude of its workers can send a message to the parents that they may be investigated or punished rather than helped. A team-oriented approach might mitigate some of the resultant stress and negative perceptions. The primary care physician often needs to serve as the family's advocate in coordinating and mobilizing others involved.
Identify a cultural consultant and/or case manager. This ideally is someone known and respected by the family. Mr. A and his parents might have benefited from close contact with a skilled case manager, who ideally could have served as a “cultural broker,” facilitating access to proper management for Mr. A's condition.
Offer and encourage biomedical and psychosocial treatments that have been demonstrated to be effective, and invest time in directly discussing concerns and barriers that families have in accepting these treatments. Explicitly state a willingness to be flexible in supporting traditional cultural treatments as part of the care plan. If Mr. A and his family had felt that their concerns and beliefs were more deeply understood, they might have been more trusting and more willing to try different treatments.
Follow through. Maintaining long-term contact and interest in the family and their problems and providing consistent and dependable follow-up are critical to families' developing trust and accepting interventions. It may be necessary to persist for some time in the face of lack of adherence to recommendations before the patient and family gain the confidence required to try new interventions if they have had previous negative experiences with “caring professionals.”
Drug names: atomoxetine (Strattera), desipramine (Norpramin and others), dextroamphetamine (Dexedrine, Dextrostat, and others), imipramine (Tofranil and others), methylphenidate (Metadate, Ritalin, and others), nortriptyline (Pamelor, Aventyl, and others).
The authors acknowledge Jean-Robert Boisrond, Coordinator of the Haitian Health Institute at Boston Medical Center, Boston, Mass., for assistance in preparation of the case and for commitment to the special needs of the Haitian people.
Cultural Currents presents clinical experience derived from the practices of clinicians caring for patients and families whose cultural backgrounds are outside of the mainstream of society. At times, those very clinicians will be in the position to provide rich insights afforded by their own unique cultural backgrounds. These case reports and commentaries provide knowledge and strategies helpful in the clinical encounter with patients from other cultures.
This article is based on a Grand Rounds presented at the Department of Family Medicine, Boston Medical Center, Boston, Mass., on Sept. 16, 2003.
The authors received no direct support related to this article.
Dr. Culpepper has been a consultant for Eli Lilly. Drs. Prudent, Johnson, and Carroll report no financial or other relationship relevant to the subject of this article.
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