Attention-Deficit/Hyperactivity Disorder (AD/HD) is a universal condition with a strong biological and hereditary predisposition that presents itself similarly across the world. Research suggests that Latino/Hispanic children with the disorder present a neurocognitive, educational, social and clinical impairment profile similar to that reported among Anglo American children with the disorder (Bauermeister et al., 2005a; Bauermeister et al., 2005b). In spite of this similarity, the cultural background of a child can significantly influence the expression of AD/HD, the meaning given to these behaviors, the level of tolerance toward them and the disposition to seek treatment (U.S. Department of Health and Human Services, 2001).
Understanding the influence of culture is especially relevant for Latino/Hispanic individuals with AD/HD since there is evidence that they are not properly identified and treated (Bauermeister et al., 2003; Leslie et al., in press). This article focuses on how the background, language and culture of Latino/Hispanic groups can have significant implications for the assessment and treatment of Latino/Hispanic children with AD/HD living in the United States.
Although Latino/Hispanic subgroups share common values and beliefs, they differ in history, race, socioeconomic position and acculturation (Zea, Quezada, Belgrave, 1994). Considerable diversity among Latino/ Hispanic groups in the United States exists, and it is not possible to talk about a uniform Latino/Hispanic culture. Any discussion about cultural values should not be indiscriminately applied to members of the Latino/Hispanic culture or to mainstream American culture for that matter.
Understanding the family context of Latino/Hispanic children has important implications for effective and culturally sensitive AD/HD diagnosis and treatment. Latino/Hispanic families are frequently in transition, so it is virtually impossible to describe what “typical” Latino/Hispanic family is like (Zea et al.,1994; Zuniga, 1992). Some Latino/Hispanic children may witness traumatic life experiences such as civil unrest and violence in their countries of origin and separation from family members due to migration. Among Hispanic American (Latinos) living in the United States, stressful experiences associated with assimilation and acculturation to a new country, culture, language and school system can contribute to temporary adjustment problems. These experiences may significantly impact Latino/Hispanic children’s emotional development and could result in behaviors that can be confused with, or aggravate, the symptoms of AD/HD.
Latinos also differ considerably in their proficiency of the English language. Understanding language barriers is essential to avoiding serious diagnostic and assessment errors in using AD/HD rating scales, questionnaires and other tests in English. Children with poor English language skills can present behaviors such as not following instructions or not appearing to listen when spoken to directly that may be confused with symptoms of AD/HD. Moreover, the fact that a Latino/Hispanic person has acquired English conversational skills does not imply that he or she has the language proficiency needed for reading and writing.
Finally, parents of Latino/Hispanic children with AD/HD that lack English proficiency and literacy can have difficulty participating in activities such as attending parent-teacher conferences, helping with homework, seeking services for their child and participating in other orientation and educational activities. This apparent lack of parental involvement can be misperceived as lack of responsibility toward the child with AD/HD. Teachers and service providers need to be aware of these language issues and their implications.Competent and culturally sensitive interpreters can be valuable in facilitating effective communication between Latino/Hispanic parents and teachers and service providers.
In spite of the background and linguistic differences described, several cultural norms appear to be common among Latinos. Two of these cultural norms are highlighted.
“Familism” refers to a perceived obligation to provide support to the members of the extended family, reliance on relatives for help and support and emphasis on interdependency (Marin & Marin, 1991).
The cultural value of familism has important implications for the successful treatment of a child with AD/HD. Latino/Hispanic families can provide much support to a child with the disorder and protect him or her from the development of conduct problems (Bauermeister et al., 2005). Also, it is likely that following a diagnosis of AD/HD, extended family members will be consulted and their opinions given considerable weight. It is essential that activities designed to educate parents and caregivers about AD/HD include extended family members. This inclusion can facilitate support; involvement; and treatment acceptance and compliance, particularly medication treatment. Service providers need to create or revise and adapt counseling and parent and family training programs to the cultural values and parenting practices of Latino/Hispanic families (Forehand & Kotchick, 1996).
The second Latino/Hispanic cultural value, “simpatía,” refers to the importance given to behaviors that promote smooth and pleasant social relationships and avoid interpersonal conflict (Marin & Marin, 1991; Zea et al., 1994). When this cultural value is predominant, Latino/Hispanic parents may appear to agree with recommendations from clinicians and educators suggested as part of the treatment for their child’s AD/HD, but fail to comply and implement them at home. Also, Latino/Hispanic parents may seldom question teachers’ and service providers’ advice, and thus may not maximize the benefits of counseling or full participation in the treatment process. Teachers or service providers who emphasize courtesy, warmth and respect in their interactions with Latino/Hispanic parents tend to be more successful in involving parents in treatment, reducing non-adherence and facilitating follow-up. When service providers establish a climate of respect, support and understanding, Latino/Hispanic parents and children will be more capable to talk about their concerns and sources of disagreement (Zea et al., 1994).
In summary, an understanding of Latino/Hispanic subcultures is essential to providing effective service programs to this group. Much is at stake in efforts to reach Latinos, given the prevalence and multiple risks associated with AD/HD over time. Practitioners, teachers and administrators all need to increase their level of cultural sensitivity if they are to be more effective in the evaluation and treatment of Latinos with AD/HD.
The risks of incorrect diagnosis can be reduced by using multiple assessment methods and sources of information from diverse settings that take into consideration the level of English language proficiency of the Latino/Hispanic person, obtaining careful developmental history of the child and family, and establishing a culturally sensitive therapeutic alliance between parents and teachers and service providers. In addition, parents must have access to culturally sensitive literature on AD/HD (Bauermeister, 2002), and discussions about the disorder should highlight the child’s diverse patterns of difficulties as well as particular qualities, abilities and skills.
Parents of a friendly and communicative Puerto Rican child with AD/HD living in the New England area were puzzled at his teacher’s serious concern that he frequently touched his peers during conversation. The other students and parents were reported to be uncomfortable with this behavior. The teacher was unaware that establishing close interpersonal contact and touching are culturally learned social behaviors among people of Hispanic heritage. At the same time, the boy’s parents were unaware that this set of social behaviors was outside mainstream American culture.
Cultural sensitivity is pivotal to understanding cultural differences in behavior. While Anglo American individuals did not understand the child’s social interaction pattern – finding them inappropriate – the child and his parents did not understand the standard behaviors of mainstream American culture and felt discriminated against. Without addressing the need for cultural sensitivity of all persons involved, it is unlikely that the child and his parents will accept or comply with a treatment program designed to modify the boy’s touching behavior while interacting with peers at school.
The situation described in the vignette can be resolved using a combination of strategies focusing on increasing the level of cultural diversity and sensitivity while avoiding stigmatization and stereotyping. For example, the teacher could talk and/or assign activities that enhance the children’s understanding of different cultures. Cultural values may be used as an example to highlight the different social interaction patterns across groups.
Aside from the classroom discussion, a dialogue between a counselor and the child and his parents should take place. During this dialogue, the counselor may provide skills that parents could use to teach the child in which contexts and with whom touching behavior is socially accepted. A cognitive behavior modification program can then be implemented to help the child achieve this goal. To maximize the efficacy of this approach, teachers and counselors should be trained in cultural sensitivity and diversity.
The following resources may be helpful for Spanish-speaking parents:
Bauermeister, J. Hiperactivo, Impulsivo, Distraído. ¿Me conoces? New York, N.Y.: Guilford Press, 2002.
García Castaño, F. Es TDAH y ahora…¿Qué? San Juan, Puerto Rico: Ediciones Hispalis, 2001.
Parker, H. Cuaderno de trabajo para padres, maestros y niños sobre el Trastorno de bajo nivel de atención (ADD) o hiperactividad. Specialty Press, 1996.
Peña, M. Así aprendo…Guía para educadores. San José, Costa Rica: Fundación DA, 2000.
Rief, S. Cómo tratar y enseñar al niño con TDA/ TDAH. West Nyack, N.Y.: The Center for Applied Research in Education, 2000.
Scandar, R. El niño que no podía dejar de portarse mal. Buenos Aires, Argentina: Distal S.R.L., 2000.
AD/HD by Other Names and Acronyms
While Attention-Deficit/Hyperactivity Disorder (AD/HD) is the official term and acronym used by today’s mental health care professionals, it is sometimes referred to by other names and abbreviations. For example, it is sometimes called:
- ADHD (without the “slash” in the middle)
- Attention Deficit Disorder (ADD)
- Attention Disorder
- Bauermeister, J.J. Hiperactivo, impulsivo, distraído ¿Me conoces? Guía acera del déficit atencional para padres, maestros y profesionales. New York, N.Y.: Guilford, 2002.
- Bauermeister, J.J., Canino, G., et al. “Stimulant and Psychosocial Treatment of AD/HD in Latino/Hispanic Children.” Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 42.
- Bauermeister, J.J., Matos, M., et al.. “Comparison of the DSM-IV Combined and Inattentive Types of ADHD in a School-Based Sample of Latino/Hispanic children.” Journal of Child Psychology and Psychiatry, Vol. 46.
- Bauermeister, J.J., Shrout, P., et al. AD/HD Correlates, Comorbidity, and Impairment in Community and Treated Samples of Children and Adolescents. Manuscript submitted for publication.
- Forehand, R.L. & Kothckhick, B.A. (1996). “Cultural Diversity: A Wake-Up Call for Parent Training.” Behavior Therapy, Vol. 27.
- Leslie, L.K., Canino, G., et al. (in press). “AD/HD Treatment Patterns of Youth Services in Public Sectors in San Diego and Puerto Rico.” Journal of Emotional and Behavioral Disorders.
- Marín, G. & Marín, B.V. Research with Hispanic Population. Newbury Park, Calif.: Sage, 1991.
- U.S. Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001.
- Zea, M.C., Quezada, T. et al. “Latino Cultural Values: Their Role in Adjustment to Disability.” In D.S Dunn (Ed.). Psychosocial Perspectives on Disability (Special issue). Journal of Social Behavior and Personality, Vol. 9.
- Zuñiga, M.E. “Families with Latino roots.” In E.W. Lynch and M.J. Hanson (Eds.). Developing Crosscultural Competence. Baltimore, Md.: Brookes, 1992.