Clinician Guidelines to Culturally Competent Care

Attention-Deficit/Hyperactivity Disorder is a highly prevalent and pervasive neurodevelopmental disorder. ADHD typically occurs in early development, prior to a child’s school enrollment and is characterized by persistent inattention and/or hyperactivity/impulsivity that affects an individual’s functioning and/or development. Individuals with ADHD can present with symptoms of inattention, hyperactivity/impulsivity, or a combination of both.

Inattention manifests behaviorally as failing to attend to details or making careless mistakes, wandering off task, lacking persistence, difficulty sustaining focus, and being disorganized. Individuals with inattentive features tend to reduce their engagement in tasks or activities that require sustained cognitive effort and may appear forgetful or distracted. Hyperactivity and impulsivity manifest behaviorally as excessive motor activity, restlessness or an inability to sit still when appropriate, appearing as if “driven by a motor”, difficulties waiting for one’s turn in social settings, social intrusiveness, and engagement in actions without recognition of the potential for harm or aversive consequences.

For a diagnosis of ADHD to be met, individuals must exhibit six or more symptoms of inattention or hyperactivity/impulsivity or a combination of both. Symptoms must be present for at least six months, are inconsistent with developmental norms, and directly interfere with an individual’s functioning. Symptoms must be present in at least two settings, such as at home, school, with peers/family, or during leisure activities.

ADHD is highly prevalent among youth and adult populations, with 11% of youth and 8.1% of adults affected during their lifetime. Recent research by London & Landes (2021) has demonstrated a significant increase in estimates of ADHD in adult populations by 24.6% in individuals aged 18-64 and a decrease in gender differences with respect to ADHD prevalence.

While estimates have shown higher rates of ADHD among men and boys, greater diagnostic clarity, symptom recognition, and systematic changes in health care have increased the assessment and recognition of ADHD symptoms in women and girls. However, disparities continue to exist for ADHD prevalence cross-culturally. These disparities in prevalence among diverse cultures may be due to cultural biases inherent in diagnostic assessment and clinical screening tools. Cultural prevalence rates may also differ, due to differences in the ways ADHD manifests in diverse cultures, interpretation of diverse youth behavior by clinicians or caregivers, and bias in rating and screening.

Despite research that demonstrates ADHD occurs in virtually all cultures and countries, the majority of the research on ADHD focuses on Caucasian Americans. However, race, culture, and ethnicity are critical to the assessment, diagnosis, and treatment of ADHD. While, searches for articles that include “ADHD” and “Race” have increased from 1990-2000, as well as reductions in bias in clinical care through diversity training that aim to reduce implicit bias, cultural biases in ADHD diagnosis continue. Furthermore, factors such as racism, stereotyping, trauma, and social disadvantage contribute to the maintenance or exacerbation of ADHD symptoms. These factors can also affect how an individual’s symptoms manifest, the likelihood an individual receives a diagnosis and treatment, and the rate of ADHD detection. Thus, recognizing how ADHD can present across various cultures is significant for clinicians and our communities.

For example, people of Hispanic heritage may be at risk for over-diagnosis, due to expectations within their culture to attend to and perform a variety of tasks during one period of time. This is in contrast to European American cultures who organize tasks and activities in a linear fashion, attending to a singular task or activity, prior to initiating another. Additionally, Hispanic culture deemphasizes structure, routine, and punctuality, whereas European Americans place a higher value on these factors. Therefore, Hispanic children may be at a higher risk of being perceived as impulsive and inattentive, symptomatic of ADHD, rather than behaving in accordance with their culture.

Because ADHD occurs during early, critical periods of an individual’s development, assessment and treatment of ADHD in all cultural groups is critical for the attainment of important skills required for a successful transition into adolescence and adulthood.

Tips for Clinicians in Providing Culturally Competent Care:

1. Identify your own cultural biases and reduce them, through:
   1. Intellectual Engagement (learning about cultural groups through articles, videos, journals)
   2. Emotional Engagement (engaging in personal reflection with own biases, attitudes, and experiences with diverse groups)
   3. Relational Engagement (developing positive relationships with people from different cultural groups)
2. Reflect on your life experiences with people of diverse cultural backgrounds
3. Consider your own experiences of discrimination. Ask yourself: “Are there aspects of your identity that impact the way you perceive others?”
4. Understand and assess key historical events, sociopolitical issues, basic values and beliefs, and cultural practices of your client.
5. Consider cultural explanations in the diagnosis and conceptualization of mental health issues.
6. Assess mental health through the use of a Cultural Formulation Interview*

Cultural Formulation Interviews in the diagnosis of mental disorders aims to identify and clarify key aspects of the presenting problem from the point of the individual and family members within the client’s social world.

A Cultural Formulation Interview:

1. Elicits the individual’s view of core problems and key concerns
2. Focuses on the individual’s way of understanding the problem
3. Uses client language in the description of the problem
4. Asks how the individual talks about their difficulties or symptoms with family and friends
5. Focuses on the aspects of the problem that are most salient to the individual
6. Obtains cultural perceptions of the cause of the problem, as well as factors that contribute to resiliency or the worsening of symptoms.
7. Identifies the role of culture as a protective or promotive factor in healing and wellness.

While little research has been conducted on ADHD in diverse cultures, and racial/ethnic minorities are less likely to be assessed, diagnosed, and treated for ADHD, clinicians can mitigate these disparities in mental health care by utilizing a culturally informed approach to care with all clients.

Specialized Therapy Associates includes staff that is highly skilled in the assessment and treatment of a wide range of mental health issues.  For a free consultation with our intake coordinator who will match you to the best provider and service to fit your needs and goals, call 201-488-6678 or visit https://www.specializedtherapy.com/make-an-appointment/ to schedule an appointment.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Centers for Disease Control (2020, November 16). Attention-Deficit/Hyperactivity Disorder  (ADHD). Data and Statistics About ADHD. https://www.cdc.gov/ncbddd/adhd/data.html

Conrad, P., & Potter, D. (2000). From hyperactive children to ADHD adults: Observations on the expansion of medical categories. Social Problems, 47(4), 559-582. https://doi.org/10.2307/3097135

Danielson, M. L., Bitsko, R. H., Ghandour, R. M., Holbrook, J. R., Kogan, M. D., & Blumberg, J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Null, 47(2), 199 212.         https://doi.org/10.1080/15374416.2017.1417860

Fletcher, J. M. (2014). The effects of childhood ADHD on adult lab market outcomes. Health

Economics, 23(2), 159-181. https://doi.org/https://doi.org/10.1002/hec.2907

Fletcher, J., & Wolfe, B. (2009). Long-term consequences of childhood ADHD on criminal activities. The journal of mental health policy and economics, 12(3), 119–138.

Evans, S. W., Owens, J. S., Wymbs, B. T., & Ray, A. R. (2018). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Null, 47(2), 157-198. https://doi.org/10.1080/15374416.2017.1390757

Hook, J.N., Davis, D., Owen, J., & DeBlaere, C. (2017). Cultural Humility: Engaging Diverse Identities in Therapy. Washington, D.C., USA: American Psychological Association. ISBN 1-4338-2779-4 (Digital, undefined format) or ISBN 978-1-4338-2779-2 (Digital, undefined format)

Iwamasa, G.Y. & Hays, P.A. (2019). Culturally Responsive Cognitive Behavior Therapy: Practice and Supervision (2^nd edition). Washington, D.C., USA: American Psychological Association. ISBN 1-59147-360-8 (Hardcover)

Lensing, M. B., Zeiner, P., Sandvik, L., & Opjordsmoen, S. (2015). Psychopharmacological treatment of ADHD in adults aged 50+: An empirical study. Journal of attention disorders, 19(5), 380–389. https://doi.org/10.1177/1087054714527342

London, A. S. & Landes, S. D. (2021). Cohort change in the prevalence of ADHD among U.S.  adults: Evidence of a gender-specific historical period effect. Journal of attention disorders, 25(6), 771-781. https://doi.org/10.117/1087054719855689

Richards, P. S & Bergin, A. E. (Ed.). (2014). Handbook of Psychotherapy and Religious

Diversity (2^nd edition). Washington, DC, US: American Psychological Association.

ISBN 1-4338-1736-5 (PDF) or ISBN 978-1-4338-1736-6 (PDF)

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Cycling as a form of exercise has been well-documented as an effective way to improve your physical and emotional health. Exercise contributes to many health benefits including improvements in sleep, heightened libido, stress relief, increased energy, weight loss, reductions in fatigue, and improved cardiovascular fitness and cholesterol. Exercise also has been shown to improve anxiety, depression, mood, self-esteem, and cognitive functioning. This because when an individual engages in regular exercise, blood circulation to the brain increases, and the hypothalamic-pituitary-adrenal (HPA) axis, which plays an integral in maintaining our body’s equilibrium and stress response, is able to regulate stress more effectively. Research also demonstrates that the benefits of exercise can be enhanced when combined with environmental stimulation, in other words – exercise in the great outdoors!

Cycling can be an extremely effective way to improve physical and mental health, as it is an accessible, low-impact, and fun way to engage your body and brain.

Benefits of Cycling on Mental Health

1. Cycling improves mood by increasing blood flow to the body, and thus the spread of endorphins and feel-good neurotransmitters, such as dopamine, norepinephrine, and serotonin.
2. Cycling helps improve self-esteem, depression, anxiety, and stress, due to the very nature of the exercise – It is reminiscent of nostalgic childhood experiences and provides environmental exposure and engagement with one’s surroundings.
3. Regular cycling has been shown to help promote better sleep quality and sleep efficiency through synchronizing circadian rhythms and reducing stress hormones that contribute to poor sleep quality, efficiency, and duration.
4. Cycling is good for our brain functioning and memory. The act of cycling contributes to the increased production of new brain cells responsible for memory and recall.
5. Cycling can offer an opportunity to engage in mindfulness. Cyclers can use a ride to concentrate on the rhythm of their breath, each movement of their legs, the wind on their face, and body to center themselves and increase positive thoughts and feelings.

Benefits of Cycling on the Brain

1. Similar to the way bike riding promotes muscle growth, it can also promote brain growth. As cycling promotes increased blood flow to the brain, this helps the brain and body pull in more oxygen and nutrients that can improve cycling performance and brain functioning.
2. Riding a bicycle leads to the production of proteins that help create 2-3x more brain cells than normal patterns of brain cell reproduction.
3. Taking a ride on a bike has also demonstrated efficacy in preventing natural cognitive decline as a result of aging.

30-60 minutes of steady riding, with approximately 75% of our maximum heart rate, 3-5 times a week, is recommended as the best cycling practice to reap the best rewards of this fun and rewarding exercise.

Specialized Therapy Associates offers a breadth of functional medicine and therapeutic services designed for health and wellness for individuals of all ages. For a free consultation with our intake coordinator who will match you to the best provider and service to fit your needs and goals, call 201-488-6678 or visit https://www.specializedtherapy.com/make-an-appointment/ to schedule an appointment.

References:

Leyland, L. A., Spencer, B., Beale, N., Jones, T., & van Reekum, C. M. (2019). The effect of

cycling on cognitive function and well-being in older adults. PloS one, 14(2), e0211779. https://doi.org/10.1371/journal.pone.0211779

MensLine Australia. (2020, May 19). Cycling – The Exercise for Positive Mental Health. https://mensline.org.au/mens-mental-health/cycling-positive-mental-health/#:~:text=Cycling%20for%20positive%20mental%20health&text=Cycling%20pumps%20blood%20around%20your,It%20promotes%20positive%20mental%20health.

Oja, P & Titze, Sylvia & Bauman, Adrian & De Geus, Bas & Krenn, Patricia & Reger-Nash, Bill & Kohlberger, T. (2011). Health benefits of cycling: A systematic review. Scandinavian journal of medicine & science in sports. 21. 496-509. 10.1111/j.1600-0838.2011.01299.x.

Sharma, A., Madaan, V., & Petty, F. D. (2006). Exercise for mental health. Primary care

companion to the Journal of clinical psychiatry, 8(2), 106. https://doi.org/10.4088/pcc.v08n0208a

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As COVID-19 cases increased around the United States toward the end of March 2020, governmental regulations issued stay-at-home orders, school closures, and caused many individuals to be laid off, furloughed, or to work from their homes. Although stay-at-home orders were intended to reduce the spread of COVID-19 and keep our communities safe from contracting COVID-19, home is not always a safe place for individuals to live, especially for adults and children who reside in homes where domestic and familial violence occurs. For these individuals, home environments are often a place where power and control predominate, and where significant others who perpetrate violence or abuse, can assert their power without intervening with others outside of the family unit. COVID-19 restrictions on movement and outside activity reduced access to escape, help-seeking behaviors, and mechanisms to cope for victim-survivors. Additionally, social norms and attitudes, with respect to family life and connectedness during the pandemic, likely contribute to increased challenges for victim-survivors to seek help, speak out, and/or leave due to increased feelings of shame, guilt, and embarrassment. As the pandemic and its restrictions continue, it is important to understand that positive conceptions of home and family life can contribute to increased marginalization and silence for individuals that live and have connections to a home life that is unsafe and may be fraught with violence.

So, how can we help deal with Domestic Violence?

What Friends, Family, and Significant Others can do to curb Domestic Violence:

Friends, family, and significant others can support others who are struggling with domestic violence by having conversations with victim-survivors. Though these conversations may be difficult, several tips can help support victim-survivors.

1. Acknowledge the situation is difficult and scary, and the violence or abuse is not their fault.
2. Let the person or family know that they are not alone and that there is help and support available to them.
3. Listen and be supportive. Telling victim-survivors what they should do or should not do will likely lead to further isolation and disempowerment. It is important that friends of victim-survivors make known that they support the individuals and their decisions.
4. Don’t be judgmental or harsh. Individuals have many reasons for why they stay in violent or abusive situations and/or leave and return to these situations. Perpetuating further shame or guilt to these individuals not only contributes to the shame and guilt they likely already feel, but can contribute to increased sensations of loneliness, isolation, and helplessness that their abusive situations already cause.
5. As much as we may want to “rescue” a person or family from violence, the only person that can save the person is themselves. Abuse and violence are about power and control, and we must do everything to empower these individuals to make helpful decisions for themselves.
6. Develop and collaborate on a safety plan with a person or family struggling with violence or abuse. A safety plan is an individualized, practical plan that can improve the person or family’s safety while experiencing an unsafe or abusive situation. This can be helping the person or family cope while remaining in the home, preparing the person or family to leave, or helping problem-solve after they leave. Safety plans include strategies to remain physically safe, emotionally safe, and sometimes involved with legal protections.
7. Help the person or family identify and build support from other family members, professionals, or people to increase the person or family’s recognition and access to safe people or places.
8. Suggest, identify, and collaborate with the person or family to find a local service provider, supportive professionals, or referral to a mental health care provider.

What Medical and Mental Health Professionals Do to Treat Domestic Violence:

1. Professionals should attend to and screen every patient for domestic violence at the beginning of visits while ensuring patient privacy by screening patients without the patient’s partner or children present, if possible.
2. Patient confidentiality should be reassured and sensitivities must be given to confirm if the patient can and has access to a private and safe place to talk.
3. Alternative methods of communication may need to be provided, and if possible, professionals should know how to provide comprehensive screening with yes/no questions. When applicable, professionals should provide nonverbal communication tools.
4. Referrals should be provided for patients who screen positive for intimate personal violence or domestic violence within their communities. Referrals to community resources can reduce psychological harm from IPV and offer support to victim-survivors. Additionally, barriers of access to resources provided should be assessed and problem-solving should be included to allow patients the opportunity to utilize the resources given.

Medical and Mental Health Professionals can search for local shelters at https://www.domesticshelters.org, search for resources by the state at https://www.womenshealth.gov/relationships-and-safety/get-help/state-resources, and find resources to use during the COVID-19 pandemic at https://www.futureswithoutviolence.org/get-updates-information-covid-19/.

If you need immediate help or need a discreet way to reach out for help regarding domestic violence, please visit The Domestic Violence Hotline   and call 800.799.SAFE (7233).

If you or someone you know is struggling with domestic violence or interpersonal violence, the trauma program at Specialized Therapy Associates can help. STA offers individual and group counseling by experienced, highly trained therapists to help individuals process trauma, reduce isolation and shame, and promote healing.

References:

1. Bradbury-Jones, C., & Isham, L. (2020). The pandemic paradox: The consequences of COVID-19 on domestic violence. Journal of clinical nursing, 29(13-14), 2047–2049. https://doi.org/10.1111/jocn.15296

2. Evans, M. L., Lindauer, M., & Farrell, M. E. (2020). A Pandemic within a Pandemic — Intimate Partner Violence during Covid-19.N Engl J Med, 383(24), 2302-2304. https://doi.org/1056/NEJMp2024046
3. Moreira, D. N., & Pinto da Costa, M. (2020). The impact of the Covid-19 pandemic in the precipitation of intimate partner violence. International journal of law and psychiatry, 71, 101606. https://doi.org/10.1016/j.ijlp.2020.101606
4. Naional Domestic Violence Hotline . (2021, January 4). Talking About Relationship Abuse. https://www.thehotline.org/resources/talking-about-relationship-abuse/.
5. Smith SG, Zhang X, Basile KC, et al.; Centers for Disease Control and Prevention; National Center for Injury Prevention and Control. National Intimate Partner and Sexual Violence Survey: 2015 data brief – updated release. November 2018. Accessed June 30, 2020.
6. Ver, C., Garcia, C., & Bickett, A. (2021, January 1). Intimate partner violence during the covid-19 pandemic. https://www.aafp.org/afp/2021/0101/p6.html.

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