Study Explores Medication Decision Making for African American Children with ADHD

June 23, 2020

Nearly 79% of White children with attention deficit hyperactivity disorder (ADHD) take medication to manage their symptoms, following a thorough diagnosis and prescription by a medical provider. Among African American children with ADHD, this number is only 27.3% — and the rate of medication discontinuation is comparatively higher as well. What causes this racial disparity in ADHD treatment? Many factors ranging from institutional racism to healthcare access to clinician education to cultural norms and beyond. In a synthesis of 14 existing studies centered around one such factor — namely, caregiver medication decision making (MDM) — researchers have recently proposed three main influences:

• Fundamental caregiver perspectives on ADHD, which are influenced by exposure to ADHD research and information, personal experience with individuals who have diagnosed ADHD, as well as cultural norms and explanations for behaviors
• Caregiver concerns about the safety and effectiveness of stimulant medications
• Caregiver mistrust in physicians and the pharmaceutical industry, fueled in part by the belief that ADHD diagnosis and treatment is a form social control that is exacerbated by culturally biased ADHD screening tools

These findings, recently published in the Journal of Attention Disorders¹ , appeared in a study titled “Medication Decision Making Among African American Caregivers of Children With ADHD: A Review of the Literature.” In it, researchers found that historical, structural, cultural, and political factors all coalesce to create health disparities that disproportionately affect African American families and strongly influence MDM.

To arrive at their conclusions, researchers analyzed seven observational studies, four qualitative studies, and three mixed method studies using the following databases: the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychINFO, PubMed, and Education Resources Information Center (ERIC). In synthesizing these 14 studies, they identified three themes that help to explain the factors influencing MDM for African American caregivers of children with ADHD, specifically.

Factor 1: Fundamental Perspectives of ADHD and Cultural Norms for Child Behavior

In reviewing various existing studies, the researchers found that “African American parents had lower ADHD knowledge, less exposure to ADHD information, and less frequent interactions with individuals with ADHD than their White counterparts.” They also found that “African American parents, some of whom were caregivers to children with ADHD and some who were not, attributed ADHD-like behaviors to origins other than medical or biological causes. Explanations of ADHD-like behaviors included poor parenting, lack of attention, insufficient discipline, or a normal stage of development that would be outgrown.” One of the studies used in the analysis found that African American caregivers “were significantly less likely to attribute ADHD to genetic origins, or apply a medical label,” and another found them almost half as likely as White caregivers to consider ADHD a real disorder.

As a result, research has shown that “White children had twice the odds of African American children to receive an evaluation, diagnosis, or treatment for ADHD, despite the fact that there were no differences in rates of recognition of ADHD symptoms.”

Factor 2: Fundamental Perspectives on ADHD Medication Among Caregivers

Studies considered in this research revealed that “significantly fewer African American parents believed medications can be effective in treating ADHD than White parents.  The odds of an African American endorsing medication as a treatment were 0.7 compared to White parents.”² In addition, caregiver concerns about sedating side effects, extreme weight changes, and obsessive use resulted in ADHD medication being viewed a last resort or refused entirely by African American caregivers. What’s more, “parents who expressed concerns about medications were 2.5 times less likely to use treatment at follow-up,” which means a higher rate of medication discontinuation.

Studies also revealed that African American caregivers perceived ADHD symptoms as typical childhood behaviors and were less likely to recognize ADHD behavioral symptoms as problematic or impairing compared to White counterparts.³ This could mean medications might not be offered to minority children based on differences in caregiver report of symptoms.

Factor 3: The View of ADHD As A Form of Social Control

One study⁴ of African American caregiver perspectives of ADHD found that participants felt the diagnosis of ADHD represented a form of social control, and was described as “something the medical people came up with to handle kids” so they “just sit like zombies.” The researchers suggested that a lack of trust in healthcare professionals contributes to this outlook and to pharmacological disparities for ADHD.

The findings of this review have many implications for clinical practice and research moving forward. Culturally based ADHD treatment disparities should be can be addressed with a patient-centered approach to ADHD management, the researchers say. Exploring beliefs, knowledge, and misgivings regarding both the diagnosis and treatment of ADHD can help to provide better patient education, pursue acceptable forms of treatment, and promote shared decision-making. Additional research is necessary to understand how assessment and diagnostic tools for ADHD are culturally sensitive and how current ADHD diagnostic rating scales are used and administered in culturally diverse communities, the research concludes.

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