Modes of entry into services for young children with disruptive behaviors

Parental intervention in school, academic pressure, and childhood diagnoses of ADHD

Childhood diagnoses of attention-deficit/hyperactivity disorder (ADHD) have increased dramatically in the U.S. in recent decades. Prior research has alluded to the possibility that high levels of parental intervention in school are associated with increased diagnoses of ADHD, but this relationship remains understudied. This study investigates: 1) whether the children of intervening parents are more likely to be diagnosed with ADHD, and; 2) whether parental intervention moderates the extent to which children's pre-diagnosis behavioral problems and exposure to strict educational accountability policies predict ADHD diagnosis. Analyses of longitudinal, population-level data from the Early Childhood Longitudinal Study-Kindergarten Cohort of 1998-99 (n = 9,750) reveal that a standard deviation increase above the mean on parental intervention in school is associated with a 20% increase in the odds of ADHD diagnosis among elementary school children. This relationship is robust to differences in children's pre-diagnosis behavioral problems, academic achievement, parental knowledge of/exposure to ADHD, and school selection, and can arise because parents who intervene in school on average exhibit heightened sensitivity to behavioral problems and academic pressure from accountability-based educational policies. In light of prior work establishing both social class and racial/ethnic differences in parental intervention in school, this positive relationship between parental intervention in school and children's diagnoses of ADHD may carry important implications for the production of inequality in children's mental health and educational opportunities.

Improving Treatment in Minority Children With Attention Deficit/Hyperactivity Disorder

Studies have shown that African American, Caucasian, and Hispanic children all have the same prevalence of attention deficit/hyperactivity disorder (ADHD) symptoms and respond similarly to treatment. However, the number of African American and Hispanic children actually diagnosed with ADHD is significantly lower than that of the Caucasian population. Consequently, the numbers of African American and Hispanic children receiving ADHD treatment is also low. This article investigates the barriers to diagnosis and treatment of ADHD in African American and Hispanic populations, which include financial limitations, differing parental views, and cultural norms. It then discusses potential solutions to help address those barriers with the hope of providing culturally sensitive care among African American and Hispanic communities.

Sociocultural issues in african american and Hispanic minorities seeking care for attention-deficit/hyperactivity disorder

OBJECTIVE

To review the sociocultural factors that may affect the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD) in African American and Hispanic minorities seen in the primary care setting in the United States.

DATA SOURCES

Searches on MEDLINE and PubMed were conducted in April and September 2012 on ADHD and its related problems and disabilities. A general search was conducted using the terms (attention deficit hyperactivity disorder OR attention deficit/hyperactivity disorder OR ADHD OR AD/HD) AND (ethnicity OR cultural OR culture). Issues of particular relevance to racial and ethnic minorities utilizing health care services were researched using the string (black OR African OR Hispanic OR Latino OR minority OR racial) combined with terms relating to access, insurance, comorbidity, high-risk behavior, treatment compliance, and nonpharmacologic modalities. Searches were limited to English-language citations, and no date parameters were used. References identified as pertinent to this review were selected for citation.

STUDY SELECTION/DATA EXTRACTION

Information revealing contrasts between minorities and the US non-Hispanic white population was organized in distinct categories, such as access to medical care and insurance, cultural attitudes, and the effects of stigmatization. The authors also provide perspectives for the primary care physician from their own clinical experience.

DATA SYNTHESIS

Rates of diagnosis of in the United States are higher for non-Hispanic whites than for minorities, yet true prevalence is probably similar across racial-ethnic groups. When the stigma of mental illness is added to the challenges faced by racial/ethnic minorities or immigrant status, patients may be especially sensitive. Underuse of clinical services may reflect economic limitations on access to care, cultural attitudes toward mental illness, and the effects of real or perceived prejudice and stigmatization.

CONCLUSIONS

Primary care clinicians in the United States should seek to become more aware of cultural factors that could interfere with the recognition and management of ADHD.

School accountability laws and the consumption of psychostimulants

Over the past decade, several states introduced varying degrees of accountability systems for schools, which became federal law with the passage of the No Child Left Behind Act of 2001. The intent of these accountability laws was to improve academic performance and to make school quality more observable. Nonetheless, schools have reacted to these pressures in several different ways, some of which were not intended. We make use of the variation across states and over time in specific provisions of these accountability laws and find that accountability pressures effect medical diagnoses and subsequent treatment options of school aged children. Specifically, children in states with more stringent accountability laws are more likely to be diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) and consequently prescribed psychostimulant drugs for controlling the symptoms. However, conditional on diagnosis, accountability laws do not further change the probability of receiving medication therapy.

Juan: a 9-year-old Latino boy with ADHD

Juan, a 9-year-old Latino male, was referred to a community clinic by his third-grade teacher for evaluation of classroom behavior problems. He is an only child and lives with both parents. At home, Juan speaks Spanish with his parents although he occasionally speaks English with his father. His father came to the U.S. from Mexico as a small child and completed the 12 grade in the U.S. Juan's mother completed 8 grade in Mexico and immigrated to the U.S. as a teenager.Juan's mother reported that he has had no significant medical problems. Her report of his behavior included an inability to focus on tasks at hand and easy distractibility. She was concerned that the principal of the school mentioned that Juan may be asked to repeat the 3 grade or change schools. In the clinic, Juan sat quietly but appeared to be daydreaming and attentive to the conversation. The pediatrician called the principal who expressed frustration with Juan's behavior. In class, he was very fidgety, did not pay attention and usually did not answer questions. He also bothered other students when they were working. The principal explained that because Juan's school was a Spanish language immersion school, there were no special education services available. If a student at the school required special education services, he or she would be transferred to another school in the same school district. An evaluation for an Individualized Education Plan (IEP) indicated that Juan had above average cognitive ability (90 percentile), with superior ability to problem solve and process information simultaneously (99 percentile). The Woodcock Johnson III (Spanish version) indicated average achievement in academic skills, with low average in reading fluency, comprehension and spelling. On the Test of Auditory-Perceptual Skills, Juan tested generally low average in all domains, and was at the 14 percentile for both auditory number and auditory word memory. On the Test of Visual-Perceptual Skills, Juan scored above the 92 percentile. Juan did not qualify for special education services on the basis on the standardized tests. However, because of the individual attention required by Juan, a transfer to another school was considered inevitable if his classroom behaviors did not improve. Juan's mother and teacher filled-out the NICHQ Vanderbilt Assessment Scale. Their responses were consistent with the diagnosis of ADHD, inattentive type. In discussion of treatment options with the family, the possibility of stimulant medication use was raised. Juan's mother was opposed to the medication because of what she had heard from her friends-that these medications had bad side effects and did not work most of the time. Juan's father, however, was in favor of the medication because it might assist Juan to stay at the school. After several clinical visits that included further information about ADHD, behavioral treatment, and reviewing information from the school, Juan's parents agreed to a trial of medication. Juan was evaluated for a follow-up visit 2 weeks after starting fourth grade; he had been taking a stimulant medication for one month. He seemed much happier about school and was proud to report that he has completed all of his assignments in school as well as homework assignments, and he did well on a math quiz. Juan's mother was also pleased with his progress. The pediatrician called the principal, who reported that Juan was an entirely different student. He now sat at his desk and wrote down the assignments. He seemed eager to learn and able to be attentive in the classroom. The principal was amazed at the difference.

Examining the meaning attached to mental illness and mental health services among justice system-involved youth and their parents

A large percentage of youth involved in the juvenile justice system experience mental health problems, yet many do not receive mental health care. In this study, we used a process-focused framework of mental health decision making to gain insight into the use of mental health services among these youth. In-depth interviews were conducted with nine youth and nine parents participating in a program servicing youth with mental health problems who have been in detention. Themes related to problem recognition, the decision to seek and participate in services, subjective norms, and juvenile justice system involvement emerged. Most families acknowledged their youth was having problems, but few defined those problems in mental health terms. This did not prevent them from seeking services, although some were not able to access adequate services until the justice system became involved. Participants were aware of negative attitudes about mental illness, and might have limited their social networks to shield themselves.

Investigating ADHD treatment trajectories: listening to families' stories about medication use

OBJECTIVE

Policymakers, federal agencies, and researchers have called for more in-depth investigation of contextual mechanisms that may explain differences in medication use among youths with attention-deficit/hyperactivity disorder (ADHD).

METHOD

We conducted qualitative interviews with 28 families from varied socioeconomic and racial/ethnic and linguistic backgrounds regarding diagnostic and treatment trajectories for their children with symptoms consistent with ADHD, with a particular focus on whether and how medication use became a part of the trajectory.

RESULTS

Four longitudinal patterns of help-seeking trajectories emerged: (1) a pattern characterized by delay to diagnosis, common among youths with complicated clinical and/or environmental pictures or primarily inattentive ADHD symptoms; (2) an initial nonmedication treatment pattern in which parents at first chose to use other modalities of treatment; (3) a reluctant receipt of an ADHD diagnosis and/or treatment pattern, mainly seen among the low-income, Spanish-speaking families; and (4) a rapid engagement in medication use pattern, characterized by directed movement to and maintenance of medication use. These patterns resulted from a dynamic interplay of explanatory models regarding the cause, course, and cure of a child's problems; the influence of extended social networks; and factors previously examined in medical utilization models. Additional themes included (1) parents' need for more information about ADHD, (2) families' desire for additional mental health and school services making medications less necessary, and (3) the importance of cultural sensitivity and a longitudinal relationship between the caregiver and clinician to enhance communication between families and clinicians.

CONCLUSIONS

These findings deserve further study in a larger, more diverse sample.

Understanding help seeking delay in the prodrome to first episode psychosis: a secondary analysis of the perspectives of young people

First episode psychosis represents a critical period for intervention to prevent future impairments and to initiate optimal interventions. Using an interpretive interactionist framework, a secondary analysis of interview transcripts was conducted based on the narratives of youth experiences of psychosis. Our goal was to better understand the factors involved in the decision to seek help (or not) from the mental health system. Findings suggest that help seeking is a social process involving a wide range of influences; two such influences are highlighted in this paper, an individual avoidant strategy of ignoring and hiding early symptoms, and the persuasive influence of significant others in the social network.