Management of ADHD in Hispanic Patients: Implications for Improving Care of Hispanic Children with ADHD
Implications for Improving Care of Hispanic Children with ADHD
The cultural, socioeconomic, linguistic and other differences between Hispanics and whites as well as those differences among Hispanic subgroups create a need for specialized care in Hispanics. Specialized care includes provisions to effectively overcome language barriers and an increased knowledge among healthcare providers regarding culture-specific practices that may have an impact on the ability of the parent to recognize the symptoms of ADHD or to seek or accept treatment. Furthermore, strategies must be employed to offset many of the socioeconomic barriers, such as lower educational status and lack of health insurance, which may be common in newly immigrated, economically disadvantaged or unemployed families.
To begin, one of the most obvious ways to overcome language barriers is to increase the availability of Spanish-speaking physicians, nurses and other healthcare providers among primary care sites that serve a significant number of non-English-speaking Hispanics. If no member of the healthcare team speaks Spanish, the use of a professional medical interpreter is recommended. Unfortunately, interpreters are frequently not formally trained or are unavailable in times of need. According to one study, interpreters made an average of 18 clinically significant errors during each pediatric patient encounter. Therefore, it is important to ensure that medical translators are fluent in Spanish and are well trained. Some physicians may be reluctant to use trained interpreters because of financial constraints. If no other options are available, clinicians may ask Spanish-speaking families to bring adult family members who are fluent in English to medical appointments; however, children should not be asked to serve as interpreters because they often do not have the cognitive or language skills needed to accurately interpret conversations of this nature. Furthermore, when children instead of adults serve as medical interpreters, the reversal of roles may be detrimental to the therapeutic alliance, as children may be unable to fully comprehend treatment plans, and they may be unable to understand the importance of the prescribed treatment. If the interpreter is also the patient, it is possible that an unwillingness to undergo treatment may cause a lack of compliance with the prescribed treatment. In addition, children who have been inappropriately exposed to emotionally charged material may be troubled.
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Whenever appropriate, ADHD information should be disseminated in Spanish and patient education materials should be written at appropriate reading levels. Because a disproportionate number of Hispanic parents are not familiar with ADHD, it is necessary to educate this group about the symptoms of ADHD and to make distinctions between behaviors associated with ADHD and those of children who are normally active. As with all caregivers, parents of Hispanic children should be advised about possible outcomes of untreated ADHD, such as increased parenting stress, difficult parent–child or sibling interactions, and marital discord.
Clinicians who suspect ADHD in a Hispanic child may benefit from the use of culturally sensitive diagnostic instruments. The validity of ADHD diagnostic instruments whose criteria were formulated for non-Hispanic children has been questioned because the behaviors of Hispanic children are influenced by their unique culture. Perhaps even more important is the use of English scales that have been translated into Spanish by medical professionals. Ensuring appropriate translation may decrease potential complications arising from the lay person’s translation of Spanish terms for which there are no precise English equivalents. Other strategies to decrease the likelihood of misdiagnosis include the use of a multimethod, multi-informant evaluation procedure that considers functional impairment rather than symptoms alone. Viagra Super Active
Among families with children who have been diagnosed and are undergoing treatment, clinicians should use direct nonjudgmental questioning to ensure that patients are adhering to treatment regimens. Because inadequate adherence may be related to parental concerns that ADHD medications will have a negative impact on their children, physicians or other healthcare providers must be able to elicit these feelings from parents in order to allay their fears by discussing current medical knowledge about ADHD medications.
Healthcare providers should be aware of certain cultural values that have been reported to influence treatment-seeking behaviors. For example, as a group, many Hispanics believe in personalismo—that is, the ability to develop a warm, personable relationship with individuals rather than with institutions—and familismo, which is a strong attachment to family expressed through loyalty, reciprocity and solidarity as well as veneration and respect for the older members of the family. The failure to include key family members, such as grandmothers, in treatment decisions may cause the excluded family member to undermine the physician’s treatment efforts. Therefore, clinicians may increase rapport with patients by seeking the opinion of respected family members, decreasing personal space during interactions, using friendly gestures and displaying a genuine interest in the life of the patient to increase the probability of patient adherence and earn the trust of the patient. Other cultural values of Hispanics that are highly valued include simpatia (lighthearted-ness) and respeto (respect). As a result, physicians who are reserved and nonexpressive may encounter decreased patient satisfaction and a lack of patient cooperation. Common forms of respect include the use of formal terms when addressing parents in Spanish and asking parents for their opinions during medical visits. zyrtec 10 mg
Another way of showing respect towards the Hispanic patient is to ask patients about their countries of origin and about the particular cultural characteristics of their countries. This practice not only demonstrates interest on the part of the physician towards the patient as a human being but also acknowledges the patient’s individuality and uniqueness, thus solidifying the treatment relationship. Physicians who treat Hispanic patients must be careful to assure that the patient is truly in agreement with the suggested treatment plan because in the Hispanic culture, especially among members of the lower socioeconomic groups, “giving assent” is considered a sign of respect towards authority figures and not necessarily a sign of “being in agreement” with the issue in question. Once physicians have gained and have been awarded the family trust (confianza), they may be consulted for a variety of family matters and will be considered a member of the family’s trusted inner circle. Cultural competence of physicians has been reported to improve patient satisfaction by Hispanic patients.
Finally, health insurance coverage must be improved for Latino children. Zambrana and Carter-Pokras have suggested a number of useful strategies to increase coverage in this population. These strategies include raising awareness about the availability of Medicaid through community outreach centers, using trained health educators, streamlining the application process for Medicaid and increasing the availability of bilingual staff to assist those who perceive the application process as overly complex. Other strategies for those who do not use employer-provided benefits include offering Medicaid to families of low-wage earners and decreasing copayment and deductible requirements of public health insurers.
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Hispanic children with ADHD must be diagnosed so that appropriate treatment may be recommended. Cultural issues, socioeconomics and language barriers, which may vary among Hispanic subgroups, are important considerations in the treatment and diagnosis of these patients. Although challenging, a number of strategies may be employed to improve the healthcare of Hispanic children with ADHD. These strategies include an increased knowledge of cultural practices among various Hispanic groups, an increased use of trained Spanish-speaking translators whenever appropriate and the use of Spanish-language diagnostic tools. To optimize treatment outcomes, health providers who care for Hispanic children at risk for ADHD must be aware of the many challenges that are involved in treating this diverse population.