Pediatric ADHD and the Cultural Psychotherapeutic Model

Despite extensive literature on the pathophysiology and pharmacology of ADHD, there is a dearth of information to guide behavioral health care of culturally diverse populations. This is particularly concerning, given the rapid growth of ethnic minority populations in the US and health disparities in these populations.2 Although differences in prevalence of pediatric ADHD among ethnicities are narrowing, rates of ADHD remain higher in non-Hispanic white children than in children of Hispanic, Latino, or Asian backgrounds.3,4 It is uncertain whether these variations in prevalence reflect inherent biological differences and/or are influenced by reporters’ (ie, teachers, parents) cultural meanings, which are a group’s most common understandings about what it expects (eg, normal and abnormal).5 Nevertheless, it is clear that the number of minority children with ADHD who access care and receive treatment is significantly lower than that of non-Hispanic white youths.2,6,7 For example, Latinos and African Americans are not only less likely to access mental health services, but when they do, they are also more likely to discontinue treatment, particularly stimulant treatment.6 The cultural psychotherapeutic framework Many cultural minority parents are hesitant to explain their children’s behavioral difficulties as a medical disorder or ADHD. Consequently, they are reluctant to believe that these difficulties can be treated with medications, and they do not follow the prescribed medical treatment. For example, a Haitian explanatory model might be that a child’s restlessness is a result of bad spirits, which could lead the family to consult a priest (ie, hougan) rather than a psychiatrist.7 When treatments match a family’s cultural values, practices, and resources, both their efficacy and patient adherence to them increase.1 The cultural psychotherapeutic framework is based on the idea that successful treatment is founded on shared (between family and clinicians) understanding of a child’s problems and goals, and of the therapeutic interventions that can be used to address them. Employing the cultural psychotherapeutic approach The cultural psychotherapeutic approach to pediatric ADHD begins with a thorough assessment of the child and his or her cultural context. The culturally informed model for pediatric ADHD can be illustrated using the following case vignette. CASE VIGNETTE Eva, a 27-year-old never-married mother of 4, immigrated to the US from rural Puerto Rico, seeking a better life for her young family. Within the first 6 months of the children’s school year, a family pediatrician referred her to a local mental health clinic for clinical assessment of her 10-year-old son, Pedro. Eva described Pedro as having serious problems: “He cannot stay still at home, school, or in church.” She eagerly shared examples of her son’s “misbehavior” and stated that she raised Pedro poorly; unlike her own parents, she was not strict enough.