Course Articles

This text-based course is an edited transcript of the webinar, Cultural Competency in Behavioral Health, presented by Sophie Nathenson, PhD.

Learning Outcomes

After this course, participants will be able to:

• Describe the concepts of cultural competency, cultural humility, and culturally competent behavioral healthcare.
• Explain three types of culturally based mental health disparities in the United States.
• Explain three evidenced-based approaches to improve health equity through culturally responsive care.

Risks and Limitations

There are a few notable risks and limitations in this presentation. It does not contain a comprehensive list of techniques or approaches for practicing culturally competent care, nor does it contain an inventory of cultural customs or attributes of any group. Any data presented is subject to change over time, population, and methods. The concepts in this presentation have differing and evolving definitions and applications across disciplines.

Introduction

I will start by introducing the sociological perspective, which I am trained in, and the social and cultural drivers of health and health disparities. Then, we'll move to defining cultural competency and related concepts. We will discuss the rationale for cultural competency in the behavioral health fields and for a systemic sociological view of cultural competency. Then, we will discuss the central components of cultural competency: knowledge, attitudes, awareness, and skills. To preface this, when defining cultural competency, we distinguish cultural competency from simply competency.

Defining Cultural Competency

Culture is a way of life. It includes a worldview, values (what is considered good or bad), beliefs (what is considered to be true), customs, and norms of behavior (the expected ways of behaving). Culture is very much related to the health and well-being of individuals. It is something to look at when it comes to health outcomes, including mental health. Competence can be defined as the ability to perform a task; when we talk about cultural competency, it includes knowledge as a foundation, awareness, attitudes, and skills to navigate the cultural concerns and problems that clients may present. Essentially, this means the ability to work with a variety of individuals across cultures, and be able to address cultural concerns, things that are culturally based or have to do with some of the bigger picture influences on that individual. 

Many times, we'll think of cultural competency not as simply the ability to perform a task or a knowledge base, a set of facts to be learned. Rather, more as qualities, some of which you may already have, and some of which can be developed over time in a continual process across the entire life course. Defining culturally competent care, it means clinicians can work with diverse clients, with a different cultural background, with variation in their responses based on this awareness of cultural differences.

A Sociological Perspective

To bring a sociological perspective to cultural competency, it is a slightly different perspective that training on specific cultural customs, and everything that makes this culture different from that culture. Instead, we are taking a bigger picture, societal of perspective. I am a medical sociologist, not a healthcare professional, and not a behavioral health professional. I'm coming from this perspective, where we're studying underlying social conditions that affect the health status of an entire group. This could be an entire society of people. And specifically, we're looking at inequalities; in sociology, as compared to psychology which studies individual differences, we are comparing group differences. This is not to say that people in a certain group are similar to each other. When we compare groups, we're looking at the health status of that group as a whole. If we see significant differences in life expectancy, physical illnesses, and mental health issues between one group versus another, what that tells us is that there may be something at a broader level within a community, within a society, that may be driving that inequality, or that difference.

When we look at the research on diverse populations, diverse is defined as non-dominant races. In the U.S., white individuals are the "dominant race." Looking at diverse populations and their perspectives, there's often a mention that being aware of systemic issues on the part of the clinician does impact the therapeutic relationship. We're going to zero in on that idea. Understanding some of the social context, even at the broadest country level and even on the global level--that knowledge and awareness impacts the relationship that you have with the client.

In our society, we have documented health disparities, and they've existed and persisted over a very long period of time. These inequities sparked the need for cultural competency. As our country becomes more diverse, as we get hip to the fact that culture does have an effect on health, these disparities and these inequities are deemed important to address. When looking at the whole health status of an entire population--again, that could be a country, county, a city, neighborhood, client base, patient population of a specific healthcare organization--if there are massive disparities, the health status of that entire group is going to go down. It causes decreases in the quality of life of many individuals. It also creates very poor metrics in terms of patient outcomes. It costs a lot more money. There are all sorts of negative impacts. Cultural competency, as a concept, is about creating more awareness and providing more knowledge to potentially reduce these disparities by providing better and more appropriate care (Phelan & Link, 2013).

From the sociological perspective, to wrap this up, we’re including the social context that goes beyond biomedical and psychological factors contributes to the manifestation of certain behaviors and disorders. When we include that social context in the mix, we acknowledge those other factors, and we can then address some of those factors that may be causing problems within a client. We'll talk more about that throughout this presentation.

Disparities Research

Taking a super broad brush of disparities research, I'll first say of the different social factors, age, race, gender, and socioeconomic status are the most studied regarding their effect on health outcomes. In cultural competency trainings and literature, there's often a focus primarily on race. Many different social factors are in the mix. We’ll look at some of the main kinds of domains of disparities, which are differences in any kind of health outcome; anything that we can measure that has to do with health. For example, Asian and Native American populations tend to have a higher prevalence of mental disorders. Black and Latinx populations tend to have a greater lifetime persistence of mental disorders.

In terms of access, minorities have fewer visits to mental healthcare services, are less likely to initially fill prescriptions for psychiatric disorders, and have higher dropout rates. This is controlling for other factors that may affect dropouts, such as language barriers, socioeconomic status, and the ability to pay for services. Tribal communities have less access and are less likely to access services. In terms of care quality, Black and Latinx individuals are less likely to receive guideline-based care, and Asians have a lower standard of care. These are very broad variables in terms of disparities, but an entire presentation could be dedicated to these disparities in a very wide variety of outcomes that have to do with mental health.

Mental Health Inequity

In terms of inequity, we differentiate between health disparities and health inequities. Health disparities are simply differences in health outcomes by group, but health inequities are disparities that are due to policy, system, practice, and access injustices. A lot of this has to do with a misdistribution of resources or a distribution that negatively affects certain groups more than others. It can be things like discrimination and racism at the individual or the system level. All of this is wrapped up into producing health inequities.

Looking at some data from the Substance Abuse and Mental Health Services Administration, SAMHSA, 69% of Black and 67% of Latinx adults were found to not be receiving any treatment for their mental health problems. 42% of Black adults and 44% of Latinx adults were not receiving treatment for serious psychiatric disorders. Shockingly, 88% of Black adults and 89% of Latinx adults were not receiving any treatment for substance abuse disorders. This paints a picture for you initially, at how different mental health access outcomes are. We can talk about why, like reverse engineering, as to what is going on at the system level to produce and contribute to this inequity. And how cultural competency can begin to address this, starting with the one-on-one level. Again, there are other social risk factors, such as gender, gender identity, sexuality, disability, and socioeconomic status, with inequities found when comparing those groups (Substance Abuse and Mental Health Services Administration, 2018).

This is important to consider that, again, while individuals in a certain social group or social status are not necessarily similar to each other in terms of individual similarities,  we're looking at the fact that these social statuses essentially lend themselves to differences in how your experience of the world is within a certain societ,y and that there are differences there.
Now, moving to the field of psychology and psychiatry. There are plenty of researchers, scholars, and people who practice in these fields that are calling for action taken to reduce disparities and to encourage cultural competency. This is not just something that is applied to healthcare, and it's also not new. We are at a point in society where public awareness of health disparities and health inequity has gone up significantly. Part of that is from events that happened during the pandemic. Everyone's at home tuning into the same news. Experiencing--at very different levels-- events at the societal level, and there is more awareness. When the concept of cultural competency entered the lexicon in healthcare 20, 30 years ago, it was not a new concept then either. It was just new on the scene in healthcare.

This goes back to 1970. "We are asking white psychiatrists to become increasingly aware of how their everyday practices continue to perpetuate institutional white racism in psychiatry." Looking at the sociological: "it means a significant reduction in economic barriers to psychiatric care, and it means relinquishing negative stereotypes" (Sabshin et al.,1970). Moving on to 1985, it's referred to as "an ethical obligation that cross-cultural skills are placed on a level of parity with other specialized therapeutic skills" (Ridley, 1985), part of the ethics of being a provider; to have the skills to serve a variety of clients and to be aware of the issues that may be disproportionately affecting these individuals. The APA (2002) says to "take precautions to ensure that their providers' potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to, or condone unjust practices." In order to do these things and engage in actions according to these calls for action, there has to be first a knowledge of cultural differences in the social context, then trickling down to what that means for individual care and that therapeutic alliance.

Components of Cultural Competency

Now, we will go over the components of cultural competency and get more in-depth, especially with knowledge, the foundation, bringing in the social context of it all. The components of cultural competency are knowledge, attitudes, awareness, and skills. Number one: knowledge. I'm adding here an understanding of the context and the relevant issues. There are other definitions of the knowledge component of cultural competency that may be more specifically about knowing and learning about specific cultures. This is important. It can open your mind to the variation and the cultural implications to care and to all sorts of aspects of diagnosis and health philosophy, the subjective nature of different illnesses, the practices and the treatment, philosophies among different cultures. We don't want to build up this knowledge base so that we stereotype. That's part of the understanding of those cultural differences. We're building on that definition of knowledge of different cultures, to make sure that the knowledge domain includes inquiring about these cultural issues impacting the client and getting that information specific to that individual client (Sue et al., 2009).

Attitudes: this can be your attitude towards diversity in general. It can include empathy, non-judgment, and the therapeutic alliance wrapped up in that domain. Next is awareness: understanding one's own biases. Self-awareness is the practice of reflecting on where you're coming from and where your culture fits into the mix. Finally, we have skills. This can include assessment and your ability to use culturally sensitive interventions. All of these components exist at the personal, agency or organizational level, the community level, and the societal level. It's not just the one-on-one. It can be as broad as society in general; the knowledge, attitudes, awareness, and skills (Sue et al., 2009).

There are other key terms and terms to know, in part because culture can be very closely associated with ethnicity or race, and it's much broader than that. Ethnicity refers to cultural heritage and traditions: shared history, nationality, country of origin, religious affiliation, beliefs, and belonging to a particular faith. Race is a conglomeration of similar physical characteristics, but that's where we associate race within society. There's a very important distinction here where it could be seen as a biological set of differences, genetic differences, but we have the research to demonstrate that two people of the same race, physically, may have actually more differences than two people who do not look alike in terms of their race.
From a sociological perspective, we look at race as a social construction, not as something biological, because the differences by race that we see in how people are treated in society, their health outcomes, and their well-being as a whole are different. There's a different social experience and a different social context. A social construction is how we define race here. Identity could be at the individual, the group, or the universal level. Someone's personal identity, how they identify, and aspects of culture they identify with are part of their core identity. Multiculturalism refers to appreciating diversity, understanding group identities and cultural differences, and welcoming that.

Getting into the knowledge component of cultural competency, we have knowledge of cultural differences, differences in customs, differences in health philosophies, behaviors, health-improving behaviors, and norms. These all affect mental health. Everything that we're talking about in terms of disparities, these components of culture and cultural competency, all affect mental health, and are documented factors and drivers of mental health outcomes. Cultural factors in mental health outcomes could be related to things like barriers to mental health care. It could be about the role of the social context that we live in. Social context is the broader set of norms, values, and beliefs in broader society. It's how people are portrayed in the media, it's the political climate, it's the economic situation of a certain society  or smaller community. It’s everything that's going on outside the individual, the things that affect us collectively and affect people in different sectors of society with different social statuses differently.

The culture of mental healthcare, the bias, or the limitations of interventions is an interesting topic because it has to do with the fact that our diagnosis and our treatment in behavioral health and healthcare have a culture to them. They're not necessarily objective in the grand scheme of things. They are also culturally based, and they're often looked at as objective because they're driven by scientific discoveries and the like. They also have a culture to them. It's very significant.

Role of Culture in Mental Health

The role of culture in mental health: these are just a couple of the ways that culture affects mental health. First, it can influence how clients present symptoms and their subjective experience. We're keeping in mind that from one culture to another there can be a big difference in the interpretation of what's happening mentally. For example, with depression: if you're in an individualistic society, you may be interpreting that as personal misery and despair. In a more collective society, you may be internalizing things at the group level, and there's less of a focus on the individual. This can seem very different to us in the United States where we're zeroing in on that individual experience.

In terms of diagnoses of mental health conditions, they vary quite widely across cultures--things like attention deficit disorder. The set of behaviors that might be used to diagnose attention deficit disorder, for example, in another culture may be more tolerated and therefore not looked at as an abnormality. That is part of the difference in interpreting and diagnosing different mental health conditions.  Symptomology can be looked at as abnormal in one society, normal in another. Whether we define something as an abnormality or a disorder is culturally based, including our own system here in America where mental illnesses are classified according to Western systems and worldviews. That's just something to be aware of. It can help us have an openness to different cultural elements when it comes to the interpretation and presentation of symptoms related to mental health issues. Just being aware of that can help cultivate that open-mindedness--not to switch your views, but to be able to gather information-- culturally relevant information--from the client that may greatly affect the relationship between provider and client (Hinshaw et al., 2011; Maslowski et al., 1998).

Cultural Factors and Barriers to Behavioral Healthcare

Moving on to more cultural factors and barriers to behavioral healthcare. These are part of that set of factors that are culturally based that drive, or at least influence mental health outcomes. There could be physical barriers and a lack of providers based on a geographical area. We see this in rural communities, but it’s not just rural communities where there's a major lack of providers. There may be a lack of providers with the same background as a client. Oftentimes people who fall into minority populations might have a desire for this, so that the cultural issues are more understandable on the part of the provider.

Cultural mistrust of mental health interventions in general can have to do with historical injustices, cultural appropriateness of intervention, and consideration of the client's values and beliefs. For example, beliefs regarding their spirituality, beliefs associated with their religion, resource barriers, lack of insurance cost, language barriers, transportation barriers, and stigma in help-seeking in terms of mental health. Sometimes there's a stereotype that there's a stigma in certain cultures in terms of seeking services, but in actuality, it's an economic barrier, not a stigma.

Racism and Mental Health

Racism is an example of the social context and how that can affect mental health. We have an abundance of research on how racism, including discrimination, profiling, and microaggressions, are linked to more emotional distress, PTSD, depression, anxiety, self-esteem issues, and alcohol, and substance misuse. It affects social wellbeing. It can affect educational attainment. It can affect physical well-being. There's a whole scientific discipline called psychoneuroimmunology. This field studies how that social context, which affects your psychology, affects your physical body. We know that the experience of discrimination over time is cumulative in terms of its effect on both mental health and physical health. You have that release of cortisol that can help you in the short term and harm you when it's a long-term production of cortisol in the body. It can affect the degradation of your body in general, your risk of heart disease, and high blood pressure. It can affect body mass index and poor overall health. All of this gets into the body (Paradies, 2006).

Societal “Structural” Conditions

Looking at societal, or we refer to them as structural conditions, different from social factors and statuses. We're looking at these again in terms of their effect on mental health. Racial segregation, controlling for socioeconomic factors, controlling for the socioeconomic status. By the way, that is a measure that includes your income, your wealth, and your occupation; it can also include education. We can look at the socioeconomic status at the neighborhood level and at the city level. Controlling for that, when we have segregated communities, it can influence and contribute to mental health outcomes.

By the way, in the field of medical sociology, one of the assumptions is that health and illness are not randomly distributed across a geographical area or across groups. So, you can imagine a map of a community and almost like a Doppler radar when we see meteorologists present the weather systems. There are hotspots of certain illnesses, certain mental health conditions, physical health conditions. When we map onto that socioeconomic status, but also things like racial segregation, we see those hotspots of illness. That tells us that it's not necessarily random. There are social factors and structural conditions that are related to those outcomes, things like mass incarceration. We know that incarceration very disproportionately affects different groups, adverse childhood experiences, and this can lead to a higher likelihood of interacting with the criminal justice system. If a child has parents that are away, that are incarcerated, this can lead to adverse childhood experiences, which most of you probably know is related to mental health, but also related to physical health, and chronic illnesses in adulthood. Institutional racism and sexism, both historical and contemporary, affects mental health.

In general, the social experience based on socioeconomic factors, gender, sexuality, religion, disabilities, and other social statuses that we call social statuses. Much of the time fits into a social hierarchy, which means not necessarily at the individual level, but within a society, there’s a difference in the treatment, the social norms and ways of interacting with people that fall into different groups. Poverty, neighborhood deprivation, and unemployment affect mental health greatly. 
Displacement, loss of culture, and sense of belonging. If a culture is physically displaced, and there are examples that go way far back into history, hundreds of years ago where if a group is displaced, moved to another location, or the culture breaks down, there are higher rates of substance abuse, there are higher rates of overdose. It has a massive effect on the entire group as a whole. Social capital is like capital, only instead of monetary resources, which means more social resources, social cohesion, and the closeness of the group.

Redlining, reduced investment, blocking out people of certain groups accessing loans and resources in general, or employment. That includes services, schools, and hospitals. A neighborhood might have their property taxes, you know, their property values go down and then the schools suffer because that’s where they’re getting their funding. They could go out of business, and they don’t have a school. All of that has a massive effect on a neighborhood, a group, a culture, the built environment, and how a community is structured to foster social interaction and safety. All of those things affect mental health (Cummings et al., 2017).

Structural Racism

Structural racism; a defined by the Aspen Institute as "A system in which public policies, institutional practices, cultural representations, and other norms, work in various, often reinforcing ways to perpetuate racial group inequity, dimensions of our history and culture that have allowed privileges associated with 'whiteness' and disadvantages associated with 'color' to endure and adapt over time." (The Aspen Institute, 2016). Suppose you hear the concept of structural racism or systemic racism. In that case, it's that level above the individual where this is something that has gone on in history and continues today, where there are simply privileges and disadvantages by group.

Structural Competence

Structural competence is a great adjunct to cultural competency. Structural competence is the ability to discern how these downstream clinical symptoms, problems, and diseases are influenced by upstream social determinants of mental health. I'll break that down a little bit in terms of upstream and downstream. Downstream factors are things that may affect a health outcome quickly. They're the things that we're observing -  clinical symptoms, suicidal ideation, or something physical like a heart attack that leads to death. Things that happen downstream are those things that fall into emergency situations. 

Going a little further upstream we have health behaviors; further upstream, the social context, relationships, family situation, home environment. Even further upstream, we have the economic level, political level, and policy level. Problems that are happening at the systemic level are identified as problems in terms of their influence on these health disparities. Recognizing the history of pathologizing responses to trauma, there are truly disturbing aspects of history and how things are medicalized and were medicalized, and pathologized. Things like drapetomania, which was defined as the desire to escape slavery. These illnesses were legitimate diagnosable illnesses, essentially justified inhumane treatment and structural racism, and impacted diagnosis and mental health treatment. In other words, a trauma response to something external was then labeled as a mental illness. When we take that to today, if we're focusing only on that symptomology and we ignore those broader social factors, we could be missing a large part of the story (Metzl & Hansen, 2014; Willoughby, 2018).

Client Perspectives of Culturally Competent Psychotherapy

Looking at client perspectives of culturally competent psychotherapy, these are some important issues: understanding cultural issues, recognizing bias, using the social justice framework, having the desire that their therapists be advocates in terms of social problems, and preference of the same race therapist. As a side note: the outcomes may not always be better--you can rest assured if you are not the same race or of the same culture as your client, it doesn't necessarily mean you’re going to be less effective.

A study showed that a cross-cultural counseling inventory had a greater impact than only the counselor rating form on satisfaction with their provider among minority clients. This shows that there is some evidence of a positive impact of practicing cultural competency. This is also a sidebar, but a very important one (Constantine, 2002; Fuertes et al., 2006).

Knowing and Not-Knowing

When we talk about knowledge and gathering all the facts, there are things we may know, but practicing and embracing not knowing, and being open about what you don't know, can be powerful. It's like taking accountability. Oftentimes in our society, if we take accountability, if we show our biases, our lack of knowledge in certain areas, it can be associated with weakness, or you may not think that you're going to be respected.

That is a cultural thing, and breaking that down can be powerful at the individual level. Knowledge can include knowledge of cultural influences on care, the efficacy of care, culturally specific resources, programs and policies, and what’s out there that could help certain groups. If you avoid sensitive topics altogether, it can be detrimental. It can be beneficial and meaningful to have that dialogue. We don't have to know at all. When in doubt, you can ask a client to explain further, and you can always ask about how the social, or political environment may be affecting them personally.

Making the Connection

We're making the connection here: how does this form of knowledge fit into the other components of cultural competency? No matter how wide-ranging your knowledge base, awareness of these broader factors matters to clients, and individual-level care is impacted by understanding this broader context.

Attitudes and Cultural Humility

Knowledge can shape our attitudes. It can help us cultivate awareness, That's a great foundation for the skills you can pick up. Attitudes refer to things like embracing diversity, inquisitiveness, and having a positive attitude towards cultural differences. Practicing cultural humility, as distinct from cultural competency; viewing other mental health paradigms (which could be very different from the paradigm we ascribe to) as having value, emotional intelligence, and avoiding stereotypes. Cultural humility is different than cultural competency, and this is the definition that I gravitate towards in terms of how it could be impactful. It's a lifelong practice of self-evaluation, self-reflection, and self-critique. You're digging deep to understand where you're coming from and your biases. It's about reduced power imbalances. As I just talked about--vulnerability and taking accountability for potential biases and potential harm-- can be very influential in the therapeutic alliance. It also could include advocacy, community outreach, and organizational partnerships. We're looking at competency as more akin to knowledge, whereas cultural humility is more about not knowing (Tervalon & Murray-García, 1998).

Awareness

Having a bias isn't necessarily a bad thing. It's your own values, your own culture, and their impact. Ethnocentrism is looking at your own culture as the standard and looking at other cultures as other, as different. This shows up even in the “DSM-5”: there is an appendix of more culturally based disorders, that are set aside. In contrast, things like anorexia nervosa, for example, are also culture-bound, but is not included in the category of culture-bound illnesses. This is an illness that is more prevalent in Western cultures. Looking at differences in the impact of social issues, we’re simply being aware of institutional and intervention bias. We’re looking at approaches to behavioral health and being aware that they aren't culture-free, and there are cultural differences in engaging with care.

Skills

There are three skills outlined by Cardemil and Battle (2003). You can suspend preconceptions about the client and the family's race and ethnicity. You can recognize that clients may be different from other members of their same racial and ethnic group. You can consider how these differences between the therapists and client could affect psychotherapy. You can acknowledge that power, privilege, racism might also be affecting interaction with clients. Erring on the side of discussion again, you might be in doubt of what the significance is of culture. You can continue to receive ongoing professional development in culturally competent practices (Cardemil & Battle, 2003). This is from 20 years ago. It still applies today.

Anti-Racist Care

Working on the level of addressing some of those social factors, this addresses internalized racism, collective trauma, and emotional regulation. Black psychologist  Kenneth Hardy talks about the concept of the assaulted sense of self. This means that there's an internalization of the externalized racism that happens at the societal and cultural levels. Once that is internalized, it can affect self-esteem. How could this affect therapy? An example is looking at self-esteem issues. Working with that just as an individual thing, versus considering that this may be societally-based. Being aware of that and engaging in discussion with the client may have a positive impact there.

We consider care differences, like over-prescribing and mistrust. We can address those issues, taking the time to explain pharmacological treatment, the reasons, the side effects, and we gather information on a wide variety of cultural factors. We'll talk about that in terms of assessment as a culturally competent skill. The American Psychological Association (2020) has deemed racism a pandemic. This is coming late to the party, but nonetheless it is part of bringing awareness of some of these issues. Looking at it as a public health issue, as a mental health issue, as a pandemic that is spreading, that can be addressed. There's a treatment for this pandemic (Cénat, 2020; Ogundare, 2020; Singh, 2019).

Culturally Competent Assessment

Moving into culturally competent assessment, there is in the "DSM" something called the Cultural Formulation Interview. We can use that to gather information related to culture. We're not assuming homogeneity. This set of assessments, and there are lots of different assessments, can gather information on how symptoms may be related to things like racism and socioeconomic issues.

Culturally competent assessment recognizes the impact of these issues, such as mass incarceration and police violence, and how these can affect individuals. It assesses both the individual factors and the collective protective factors, strengths, and resources. Resources could be religious and spiritual, and culturally-based. It could be a culture where there's more social cohesion, or more collectivist, and these can be a strengths and protective factors. For all of the risk factors, there are also protective factors. We're going to look at two frameworks for culturally competent assessment.

• The RESPECTFUL Framework - An acronym of the different aspects of culture (D'Andrea  & Daniels, 2001):
  • R-religious/spiritual identity
  • E-economic class background
  • S- sexual identity
  • P-level of psychological maturity
  • E-ethnic/racial identity
  • C chronological/developmental challenges
  • T- threats to well-being and trauma
  • F-family background and history
  • U-unique physical characteristics
  • L- location of residence and language differences

This is information you may be already collecting; it can serve as a base for conversation and deepen your understanding of your client.

• The ADDRESSING Framework – is similar and also an acronym (Hays, 2001).
  • A- age/generation
  • D- disability status (developmental)
  • D- disability status (acquired)
  • R- religion/spiritual orientation
  • E- ethnicity
  • S- socioeconomic status 
  • S- sexual orientation
  • I- indigenous heritage 
  • N- national origin
  • G- gender

Other Scales and Tools

I mentioned the Cultural Formulation Interview and there is a Trauma Symptoms of Discrimination Scale. Deepening your understanding of discrimination and how that gets into the mind and body is fascinating. There's lots of research on how the social environment gets into the body and is passed on generationally. There's research that, for example, our grandmother's social environment affects our genetics. The field of epigenetic studies this. Consider two generations ago, and what was going on in society two generations ago. It’s pretty bad now, in terms of inequality, but go back two generations. There are other sets of issues that can have an effect on present day, the present generation (Cénat, 2020). Other tools: Everyday Discrimination Scale, UConn Racial/Ethnic Stress and Trauma Survey and, again, the Cultural Formulation Interview.

Communication

Communication applies to any client, but these are some tips when it comes to developing culturally competent skills in communication. You may already do this, but it's food for thought to take into your day-to-day. You can ask clients to describe their identity versus prescribing an identity (again, learning about a culture and then putting that on them or making those assumptions may not be exactly correct). You can ask about ideas, experiences, and beliefs. Consider that cultural and historical factors influence the etiology, symptom presentation, interpretation, how they talk about their mental health issues, and how that interacts with family pressures, cultural pressures, and stigma. The idea that therapy for a long time was associated with something that white individuals did. In your one-on-one communication, just knowing, and not assuming that there’s a universal in terms of symptom presentation and diagnosis. Note in-group differences to avoid inaccurate assessments or racial bias. Again, that's turning the cultural knowledge into a stereotype--avoiding that.

Resisting avoiding gathering information due to discomfort, and moving through discomfort. This applies to all of our relationships, right? When there's a conflict, when there's tension, when there's a power differential--being able to break that down and work through that can lead to a more meaningful connection. You can also consider more structured interviews versus unstructured ones. That relates to that discomfort. If there's a lot of discomfort, needing to know how to start the conversation, how to keep that conversation going, or what to take from it, you can use more structured interviews to gather that information as a starting point.

Beyond the Individual: Community-Based Interventions

As was mentioned before, cultural competency is a continuum, but it's also a continuum from individual all the way up to the policy level. You can integrate community-based interventions. This might be something that you do, and it might be something at the agency level. Many coalitions in communities have certain goals to address health and social issues in that community. I lived in a small town for many years, and there were many coalitions of people that came from different cultural backgrounds and political ideologies, and there were common goals. For example, ending child abuse or raising the high school graduation rate in the county. Understandably, you have, probably, a heavy workload and a lot going on. Being able to go outside of that, if you do have the time to join those coalitions, you can bring your expertise in the mental health field to interventions, whether that's disseminating mental health information or partnering with those community organizations or coalitions to bring that expertise. You can bring ideas to the table, assist individuals with resources and access, and even provide services. What we're talking about here is meeting people where they're at. If there's a barrier to care, doing something like a pop-up where you're providing some care, or maybe some assessments, similar to pop-up medical care, like a pop-up diabetes clinic or providing oral healthcare.

Policy Recommendations: Education and Research

Now we get into policy recommendations. We have covered the societal view and different societal issues, social factors, systemic issues that affect mental health. How structural issues have a trickle-down effect on clients. How those issues can be embedded, not only in their mind but in their body, and can affect how they are engaging with their mental health.

After looking at that big picture and how that affects individual care, now we’re moving back up to that policy level, which is something that many folks in the mental health fields have called for in terms of engaging more at that policy level as a mental health professional. At the educational level and the workforce level: recruiting, mentoring, and striving for a more diverse workforce. It does matter to have professionals at the table with that lived experience, and have more options for clients to have a provider who is of the same race, or cultural background that, again, may be more understanding of those issues. That’s not to say that there can be an assumption there when two people are of a similar culture. The same skills apply to collecting that information specific to that individual. 

The educational level: inclusion of cultural competency education and looking at different forms of education. I've tried to find evidence of when training works, because the truth is that the disparities we see persist. They're not going away. There is a question, and there is a debate: is cultural competency training making an impact? That's why, personally and professionally, I'm passionate about looking at that big picture, and including cultural humility. The educational practice that is a best practice is experiential learning. Spending time in a certain community with a different culture than you and becoming kind of embedded. Communicating, but mostly listening to people in that group that is different from your background, is very influential in that attitude and awareness piece.

We want to dedicate time and resources for any mandated training. If you're having to go to a training (and you're going to a training right now), having that time, and having resources. If it's happening at the organizational level, it’s putting time and resources behind that. Advocacy for interpreter services, incentivizing buy-in at the leadership and administrative levels, and expanded funding from government agencies and hospital systems to improve cultural competency (McGregor et al., 2019).

At the research level: this is critical as there is an unbelievable dearth and lack of research on the efficacy of therapies on a variety of different cultures and races. Research is needed on these underlying factors that explain these disparities, not just at the individual level. Program evaluation of cultural competency training: as I said, finding where the best practices are. More research on the client experience and more assessment of these other components like humility and empathy, and I would add vulnerability and accountability. Assessing when those skills and qualities are present, what's the effect on the health outcome? More diagnostic research, looking at the reliability and validity of different assessments, increasing studies on diverse populations, more diversity among researchers, and interdisciplinary approaches. As mentioned, those other fields such psychoneuroimmunology added to the research base (Ogedegbe, 2020; Singh, 2019).

Summary

There's a difference between cultural competency and competency, right? Cultural competency is a set of qualities. It's a lifelong practice that includes inner work for us to do. Based on what we know, the quality of the interaction is more important than anything. That's what we want to influence. We can't assume that knowledge of cultural differences automatically translates into more effective interventions (Shim, 2020).

Our general knowledge is very good for understanding that there are cultural differences and systemic inequalities. That's our base, and then we grow into being more comfortable discussing these issues and working on that humility piece. The empathetic inquiry is preferable over extrapolation, or taking your knowledge base and making those assumptions. Finally, a holistic approach to cultural competency also can include outreach, advocacy, and even engagement with policy change. 

Thank you. Your time is appreciated.

References

Alarcón, R. D., Becker, A. E., Lewis-Fernández, R., Like, R. C., Desai, P., Foulks, E., et al. (2009). Issues for DSM-V: The role of culture in psychiatric diagnosis. Journal of Nervous and Mental Disease, 197, 559-560.

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57(12), 1060-1073. [PubMed: 12613157]

American Psychological Association. (2020, May 29). ‘We are living in a racism pandemic,’ says APA President.

The Aspen Institute. (2016, July 11). Terms you should know to better understand structural racism.

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Owusu Ananeh-Firempong, I. I. (2016). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports.

Cardemil, E. V., & Battle, C. L. (2003). Guess who's coming to therapy? Getting comfortable with conversations about race and ethnicity in psychotherapy. Professional Psychology: Research and Practice, 34(3), 278.

Cénat, J. M. (2020). How to provide anti-racist mental health care. The Lancet Psychiatry, 7(11), 929-931.

Constantine, M. G. (2002). Predictors of satisfaction with counseling: Racial and ethnic minority clients’ attitudes toward counseling and ratings of their counselors’ general and multicultural counseling competence. Journal of Counseling Psychology, 49(2), 255–263.

Cummings, J. R., Allen, L., Clennon, J., et al. (2017). Geographic access to specialty mental health care across high- and low-income US communities. JAMA Psychiatry, 74, 476-484.

D’Andrea, M., & Daniels, J. (2001). Respectful counseling: An integrative model for counselors. In D. Pope-Davis & H. Coleman (Eds.), The interface of class, culture and gender in counseling (pp. 417–466).

Fuertes, J. N., Stracuzzi, T. I., Bennett, J., Scheinholtz, J., Mislowack, A., et al. (2006). Therapist multicultural competency: A study of therapy dyads. Psychotherapy: Theory, Research, Practice, Training, 43(4), 480–490.

Gurung, R. A. R. (2019). Cultural influences on health. In Cross-cultural psychology: Contemporary themes and perspectives (pp. 451–466).

Hays, P. A. (2001). Addressing cultural complexities in practice. Washington, DC: American Psychological Association.

Hinshaw, S. P., Scheffler, R. M., Fulton, B. D., Aase, H., Banaschewski, T., Cheng, W., et al. (2011). International variation in treatment procedures for ADHD: Social context and recent trends. Psychiatric Services, 62(5), 459-464.

Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science & Medicine, 12(2B), 85-95.

Maslowski, J., Jansen Van Rensburg, D., & Mthoko, N. (1998). A polydiagnostic approach to the differences in the symptoms of schizophrenia in different cultural and ethnic populations. Acta Psychiatrica Scandinavica, 98(1), 41-46.

McGregor, B., Belton, A., Henry, T. L., Wrenn, G., & Holden, K. B. (2019). Improving behavioral health equity through cultural competence training of health care providers. Ethnicity & Disease, 29(Suppl 2), 359.

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126-133.

Ogundare, T. (2020). Culture and mental health: Towards cultural competence in mental health delivery. Journal of Health and Social Sciences, 5(1), 023-034.

Ogedegbe, G. (2020). Responsibility of medical journals in addressing racism in health care. JAMA Network Open, 3, e2016531.

Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and health. International Journal of Epidemiology, 35, 888-901.

Phelan, J. C., & Link, B. G. (2013). Fundamental cause theory. In C. Bird, P. Conrad, A. Fremont, & S. Timmermans (Eds.), Medical sociology on the move: New directions in theory (pp. 105-125). Springer.

Ridley, C. R. (1985). Imperatives for ethnic and cultural relevance in psychology training programs. Professional Psychology: Research and Practice, 16(5), 611-622.

Sabshin, M., Diesenhaus, H., & Wilkerson, R. (1970). Dimensions of institutional racism in psychiatry. American Journal of Psychiatry, 127, 787-793.

Shim, R. S. (2020). Mental health inequities in the context of COVID-19. JAMA Network Open, 3, e2016531.

Singh, S. P. (2019). How to serve our ethnic minority communities better. The Lancet Psychiatry, 6(4), 275-277.

Substance Abuse and Mental Health Services Administration. (2018). National Survey on Drug Use and Health: African Americans.

Substance Abuse and Mental Health Services Administration. (2018). National Survey on Drug Use and Health: Hispanics, Latino or Spanish Origin or Descent.

Sue, S., Zane, N., Nagayama Hall, G. C., & Berger, L. K. (2009). The case for cultural competency in psychotherapeutic interventions. Annual Review of Psychology, 60, 525-548.

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117-125.

Willoughby, C. D. (2018). Running away from drapetomania: Samuel A. Cartwright, medicine, and race in the Antebellum South. The Journal of Southern History, 84(3), 579-614.

Editor’s Note: This text is a transcript of the course Understanding and Supporting Children and Teens with ADHD, presented by Heather Schmitt, PhD, LP.

Learning Outcomes

After this course, participants will be able to:

• Define ADHD, including common symptoms and features
• Describe brain-based developmental differences between children with ADHD and their neurotypical peers
• •dentify strengths and support areas in children and teens with ADHD
• Describe practical, evidence-based strategies that promote self-regulation and executive functioning skills

Introduction

Regarding the limitations and risks of this topic, I'll be talking about this from a neurodevelopmental perspective. Although it's based on the latest science and research, other approaches to treatment or perspectives can enhance progress or understanding that aren't incorporated in this specific course. Also, this course, as titled, will focus on child and teen populations. I will not be addressing young adults or adulthood.  Additionally, my training and expertise as a licensed psychologist have been developed in the context of clinical settings and a background in school psychology.  I'm not a certified neuropsychologist. I don't conduct hospital-based work.  Lastly, this course will not be a deep dive into the topic; rather, it is intended to provide a nice breadth of knowledge.

Abbreviations

Some abbreviations that will be used throughout the course are listed below.

• ADHD: Attention-deficit/hyperactivity disorder
• ADHD-I: ADHD, predominately inattentive presentation
• ADHD-HI: ADHD, predominately hyperactive-impulsive presentation
• ADHD-C: ADHD, combined presentation
• EF: Executive functioning

ADHD Defined

I want to define ADHD and provide some background information from a diagnostic standpoint so that you have an accurate understanding of what it is.  Under the umbrella of ADHD, there are different ADHD presentations.  In other words, diagnostic labels are used to describe ADHD, and they are based on two different types of clusters of symptoms.  There is the inattentive cluster (ADHD-PI) which was previously known as ADD, there is the hyperactive-impulsive cluster of symptoms (ADHD-PHI), and there is the combination of both (ADHD-C).

Previously and pretty extensively, these were called types of ADHD. Very recently, there's been a change to that wording to call them presentations. The change was made to emphasize that at different times an individual with ADHD may have more or less of one of those dimensions present. It's not a distinct or separate type of ADHD. 

ADHD-PI

The first presentation is the primarily inattentive type. This tends to be the child or teenager that might be described as a daydreamer or a "scatterbrained" individual. They have a lot of difficulties maintaining attention and listening, following through with different instructions and tasks, and keeping tasks and physical materials organized. They are easily distracted by things going on around them.  They might be forgetful and lose or misplace items. They have difficulty with attention to detail, and these children might avoid or dislike tasks that require sustained mental effort, which tends to be a lot of academic-focused work.

The highest rate of inattentive presentation is among adolescents. That means that of all of the individuals preschool through adolescents diagnosed with ADHD, the highest rate is among adolescents. Think of it as the expectations of younger children versus those of older children as they mature. It kind of matches development. Difficulties with these skills will be noticed more in adolescents, and these types of skills can become even more critical to success and independence.

ADHD-HI

The next presentation is the hyperactive impulsive predominant presentation. This is the child who is often "driven by a motor." They might be fidgety or restless, have difficulty staying in their seat, or prefer to stand up to do things. They might run or climb around excessively. They have difficulty doing things quietly, even if it's playing by themselves or speaking when it's a quiet environment. The child may talk excessively and may impulsively blurt things out rather than waiting to share what they have to say. They interrupt others and have difficulty waiting their turn.

For this presentation, the highest rate is among the preschool population. As children age towards school age and adolescence, that percentage is lower. You'll see why when I talk more about brain development. 

ADHD-C

Third is ADHD-C, which is the combined presentation. With all the symptoms mentioned above, these children show a fair number of both of those clusters of symptoms. The highest rate of ADHD-C tends to be among school-aged children. Developmentally, it makes sense that difficulties with those skills become more apparent versus observing a preschooler or an adolescent who might have ADHD.

According to the DSM-V, there are other factors to consider for a child to be diagnosed with ADHD. First, it has to emerge in childhood and be inconsistent with what we would expect for their age in terms of their ability to sit still, pay attention, remember things, etc.  Typically we expect to see this earlier in childhood; at least has to be by age 12.

Also, the number of symptoms that must be present differs by age. Up to age 16, six of the previously mentioned symptoms must be present to meet the criteria for that presentation. If they're 17 years old or older, then five of those symptoms must be present. Think of each of those presentation clusters as a group of symptoms. If a child has six or more symptoms in the hyperactive-impulsive cluster, then they meet the criteria.  Do they have six or more inattentive symptoms? Then they meet the criteria for ADHD-PI. If it's both, then they would be combined.

The DSM-V also has a specifier for the amount of impairment or how severe those symptoms are. A child may present with symptoms in two clusters, but it may minimally impact them at home and school. An ADHD-Combined presentation might also be mild. But if a child presents with eight inattentive symptoms and, two of them are hyperactive-impulsive, but there is considerable impairment across all settings (social, academic, home, extracurricular), then that child would be diagnosed with ADHD, primarily inattentive, and specified as severe.

The ADHD Brain

Next, I want to describe the ADHD brain. This is important for understanding what ADHD looks like and why.

Genetic Factors

ADHD is highly hereditary. Genes are the biggest contributor to ADHD. It's truly one of the most genetically-influenced disorders. It exceeds anxiety, depression, and many other disorders that we know are heritable. It is rivaled, maybe, by bipolar disorder and autism, which are also fairly similar in hereditariness.

We know about genetic factors because of different family studies. For example, research has shown that there is an elevated risk of ADHD among biological relatives of children that have been diagnosed. Depending on the study, 10-35% of biological relatives are at risk of having ADHD when a child does. If a parent has ADHD, there's a risk of up to 57% of children presenting with it. All of that speaks to the high hereditary factor.  We also know through adoption studies that there is no increased risk of ADHD. This further supports the role of genetics and biology. When discussing genetics, we typically don't attribute ADHD to chromosomal abnormalities, differences, or extra chromosomes. For example, we don't see Fragile X or Down's syndrome as causing ADHD. However, children with those rare genetic abnormalities may be at increased risk for developing ADHD or presenting with those symptoms.

Neurological Factors

Many neurological factors related to ADHD can be tied to brain structures and how they function. MRI studies and other brain imaging have shown differences in the volume or the size of select brain regions and reduced blood flow to these particular regions. There is typically a  significantly smaller right frontal region of the frontal lobe, which is kind of the "boss" of the brain.

Areas like the basal ganglia, corpus callosum, and anterior cingulate cortex are impacted regarding executive functioning skills as well as other higher-order skills that I will discuss shortly. Basically, structure and functional differences emerge when an individual has ADHD.

We also know there are many neural networks. One network seems to relate to hyperactive symptoms or motor systems in the brain being highly active. Another network underlies more of the attentional symptoms related to planning-related executive functioning skills. A third network mediates or impacts impulse control, and a fourth neural network explains self-regulation difficulties which is a type of gateway to the emotional brain or when the limbic system gets highly activated. All of these networks are known to influence the presentation of ADHD symptoms.

The last neurological factor related to ADHD is neurotransmitter deficiencies. This hasn't been as established as the other factors, but there is clearly a role for dopamine and norepinephrine levels. We know this because individuals with ADHD often respond positively to stimulant medications that address neurotransmitters distributed in the brain's neural networks described above.

Environmental Factors

Several environmental factors can cause ADHD. This does not include psychosocial factors like teaching or child-rearing approaches. There is no current credible evidence that ADHD exists purely because of social factors. With environmental factors, I'm referring to how things in the environment might interact with the genetic factors that a child is predisposed to. Those types of factors, particularly environmental biological factors, can impact the development of ADHD.  For example, exposure to toxins (e.g., smoking, alcohol) during pregnancy and fetal brain development has shown some relation to ADHD causality. Also, low birth weight, any associated minor brain hemorrhaging, and environmental toxins, such as postnatal lead exposure in the first two to three years of life, can cause ADHD.

Role of Medication

Lastly is the role of medication. There's a growing amount of research suggesting that treating ADHD with medication may actually result in more normalized brain development. Basically, there is a neuroprotective effect, meaning comparative medications are never used if there's an effective dosage of a stimulant used to increase brain activity in underactive neural networks. We see continued increases in the functioning of those brain regions with that medication use. So, functioning can be closer to typical as those medications are used.

Brain Development: ADHD versus Neurotypical

An important way to think about and understand the neurodevelopmental basis of ADHD is by comparing brain development between individuals with ADHD and their neurotypical peers. An imaging study by Shaw and colleagues (2007) compared how the brain matures in ADHD versus neurotypical peers. Maturation in these studies is defined as the cerebral cortex thickening. When the outer layer of the brain, that neural tissue (i.e. gray matter), is at its peak thickness, that is considered maturation. Once the brain reaches that point, it starts thinning, which is that "pruning stage" you may have heard of in brain development. The purpose of that pruning stage is to make the brain more efficient post-puberty during the teenage years. So scientists want to know when does the brain reaches maturation, meaning it's heading into that pruning stage and becoming more efficient. When scientists looked closely at the ADHD brain compared to normal development, they found that the ADHD brain follows the same pattern of maturation, but the rate is quite delayed in children with ADHD.

For youth with ADHD, the researchers found, on average, a three-year delay in different brain regions compared to their age-matched peers. Specifically, they found a delay in the maturation of the prefrontal cortex, which is largely responsible for executive functioning skills and often affected by individuals with ADHD. 

Interestingly, the motor cortex matured faster in the youth with ADHD. Researchers speculate that this mismatch might account for some of the restlessness and fidgety symptoms that are common in children with ADHD. The thought is that the brain is maturing at a different rate, and there is a big gap in the difference at that maturation stage, a three-year difference when a child has ADHD versus a child who doesn't have ADHD.

Common Myths

It is important to understand common myths of ADHD so that we can debunk them when they come up in different situations. 

Myth 1: ADHD doesn't exist

The first myth is that ADHD doesn't exist. The child's just lazy, and they're unmotivated. I hear or see these labels a lot. At the same time, some youth who struggle with ADHD have passions and strengths outside of the classroom. I always encourage families and other professionals to reframe this idea of a child being unmotivated. It is more likely that they have a skill deficit. It's not that they won't do a certain task as a matter of principle or because they're lazy, it's because they can't do it.  In terms of ADHD not existing, plenty of research validates that ADHD is a neurological lifelong disorder.

Myth 2: Someone with ADHD cannot pay attention and/or sit still

The idea that someone with ADHD cannot pay attention or sit still is false. There are times when they can sit still and/or pay attention.  ADHD affects people in non-preferred, difficult tasks or demanding environments. For example, attentional difficulties occur when the child's expected to sit for a long period of time and there are a lot of demands on their attention, versus sitting still while passively watching a movie about a topic they're very interested in. This can be really frustrating about ADHD and how it presents for certain people. It's consistently inconsistent sometimes. A child might be able to do something in one situation or in one setting, but they struggle the next time. 

Myth 3: Someone with ADHD cannot complete their work, get good grades/test scores

ADHD is not related to intelligence or IQ. I'm sure you've also seen this often: "When a child with ADHD can pay attention, they're quite smart." It's not about being unintelligent. There are many gifted individuals who also have ADHD.

Myth 4: ADHD can be caused by the environment - like parenting approaches or TV/video games

As I said before, no credible evidence indicates that social environment alone can lead to a child developing ADHD. We know because of the sibling and twin studies I referenced earlier. After accounting for those genetic factors, there's little variation that can be explained by other things. Social factors like parenting approaches or video game use certainly impact functioning and possibly outcomes for a child, but they do not alone single-handedly create ADHD.

Myth 5: Medication can cure ADHD or become addictive

Another myth is that medication can cure ADHD or, problematically, ADHD meds become addictive. First, there are no medications that cure ADHD. The medications are used to effectively treat the symptoms and address the brain-based differences so the person can manage tasks temporarily.

Regarding addiction, there is no credible evidence that using stimulant medications to treat ADHD in childhood leads to an addictive disorder in adolescents or adulthood. That said, are there individuals who misuse stimulant medications? Of course. But when those medications are used as prescribed, in a therapeutic dose, there's no evidence of addiction. In fact, there's evidence of quite the opposite. With appropriate use, medications can be a protective factor.  In other words, it decreases the likelihood that someone will misuse substances to self-medicate or unhealthily cope with difficulties that arise.

Myth 6: Children eventually outgrow ADHD

The last myth is that children eventually outgrow ADHD. Although there are many ADHD symptoms that improve over time, most adults diagnosed with ADHD at a young age have some difficulties that persist. Remember, since the normal pattern of maturation is simply delayed, that can explain why many youth with ADHD are first described as immature. Their brain development is likely similar to a child that is younger at that point in time. But as the child ages, that maturation starts to catch up to their peers a bit. It may seem like they outgrew it, but what is really happening is that gap or difference in maturation and brain development starts to close as they age.  By age 15 or 20, those functioning differences or discrepancies become less noticeable or milder in presentation than their peers.  But they aren't actually outgrowing it 100%.

Identifying Strengths and Support Areas

It's important to identify strengths and support areas for any child, particularly the child with ADHD because it's highly likely that he or she has received much negative feedback about their areas of difficulty. Think about some behaviors that can be disruptive or challenging, particularly for hyperactive impulsive children. Researchers have found that children with ADHD are exposed to much more criticism and correction than their neurotypical peers. They're often viewed and described as not living up to their potential. They are labeled the class clown, disruptive, the troublemaker, and lazy.  In fact, this is so significant that experts in ADHD have estimated that by age 12, children with ADHD have received 20,000 more negative messages from their parents, teachers, or their peers than children without ADHD. That is a significant number.

Think about the classroom.  It's probably realistic to guess that a child with ADHD might get a negative correction or a comment from a teacher every 20 minutes or three times an hour, "Sit down in your seat." "Go back and focus on your work." "Stop talking to your friend." "Get started." A student is in class for six hours a day, 180 days a year.  That's more than 3,200 corrections or criticism statements that are directed at that child. They're not ill-intended, but that's a lot of negative feedback. That's not including parent comments, coach comments, corrections, or comments from their peers. The point is that these youth are at risk of developing a damaged view of themselves and a negative view of school. So, it becomes very important to incorporate strengths into a child's everyday life. 

Find out what the child is passionate about and good at.  It is important to actively embrace their strengths and what they care about outside of school. Incorporate those things, and give them attention and value. I can't emphasize this to parents enough. Children with ADHD are just as smart as other children. They're often creative, outgoing, intuitive, artistic, and artistic. They have the ability to become wildly successful adults. Let's ensure we're doing justice to those attributes.

Another important aspect when working with a child with ADHD is to recognize that they work harder than most of their peers because the world is not built for their brain. A child with ADHD tends to struggle a lot in that traditional academic setting where you sit still, you listen, you pay attention, you do worksheets, et cetera.

They spend so much time, about six hours a day, doing tasks or activities that can be excruciatingly difficult and not super-rewarding for them.  It's actually a strength that they are managing to get through the academic world. A good analogy is it's like being on an NBA team, but you're the shortest guy. You made it to the NBA, and you're obviously a skilled basketball player, but you probably had to work a lot harder than someone who was tall. You might have to compensate and come up with skills like a fancy hook shot or a drop back three in order to play at the level of your taller teammates.

Another way to support those with ADHD is to meet them where they are. We should not be making expectations based on what a same-aged peer can do or what a neurotypical sibling did at that age.  Often, ADHD challenges aren't about a knowledge deficit; rather, the child just can't perform. So think about how can we get this child one step closer to performing while meeting them where they are.

We also want to regularly recognize growth, especially when they receive criticism and corrections. Find ways to give positive feedback and praise even those small steps towards success. Encourage teachers, parents, coaches, et cetera to be extra mindful and do it in a systematic way. For every one criticism or correction you're giving (it's okay to do that), be sure to give them at least three to five positive reinforcement comments. Provide some praise that's deserved for how hard they're working.  This might require looking outside the school arena. Balance that need of, "We're going to focus on you getting your homework done and succeeding academically," with what the do outside of the school. Where can we give them their praise?

Another aspect related to embracing strengths and understanding is psychoeducation. Often, the child misunderstands what ADHD is, and there can be a lot of stigmas.  For example, I recently started meeting with a middle schooler who had previously been in therapy to target difficulties with organization and impulsiveness. He's taking medication but didn't understand why he was taking it.  He also didn't know he had ADHD. So I spent some time explaining what ADHD is and isn't so that he could better understand his brain and why certain things are hard. As we discussed that, he explained that students at his school use ADHD to mean stupid or dumb. So, it was basically a derogatory statement.   And he honestly believed that's what it meant. When he learned he had ADHD, he thought that meant he was stupid or dumb. So that education piece is so important.

Lastly, we must practice flexibility and creativity.  Think about those passions and strengths the child has and how you can change what you are doing or how you can structure tasks to help the student succeed.  For example, I frequently give breaks for focus time and work time and therapy. Instead of doing a fun activity at the end of the session, I do 15 minutes of focus and work and then take a short break to do a fun or physical activity. I am also more intentional with incorporating movement around the room.  I'm finding ways to embrace that child's activeness and incorporate it as a strength in the work that they need to do in therapy. 

Some additional examples of strengths are: 

• Can do many things at once
• Ambitious
• Have many different ideas
• Can tell when others are hurting
• Strong emotions
• Determined, won’t easily give up
• Social
• Passionate about things interested in
• Love telling others their opinion
• High energy
• Love to move around
• Adventurous
• Kind to people
• Imaginative, creative
• Great with animals
• Good at knowing history
• Play video games well
• Amazing builder
• Very artistic

The idea is to reframe our thinking.  It might be easy to say the child is too distracted. However, we could say the child can do many things at once. Rather than saying a child is overly sensitive, maybe we say they can really tell when others are hurting. Rather than saying a child is too talkative, we can say that they love telling other people about their opinion, which is a strength. 

Support: Self-Regulation & Executive Functions Skills

Although there's no single agreed-upon definition of what executive functioning (EF) is, many agree that it's often a key deficit area for children with ADHD. All of these different processes are housed in the prefrontal cortex of the brain, where that slower maturation occurs.

These abilities center around the concept of self-regulation. Self-regulation is any action an individual directs at themselves to result in a change in their behavior to achieve a certain outcome or goal in the future. All of these different skills, organizing and starting, staying focused, keeping our attention there, managing distractors, and keeping our emotions in check, are working together to help us toward that goal.  They involve regulating ourselves. Regulating our behavior, regulating our emotions, and regulating our brain or our cognitions.

Here is an example. I have a New Year's resolution to eat healthier snacks with less sugar. I walk into a coffee shop and immediately see this beautiful display of pastries and cookies. The situation might tempt me to buy something that will ruin my resolution. To deal with that, while I'm waiting for my latte, I focus on my phone instead of the cookies. Or maybe I'll walk to the far side of the shop so I don't see them as much. I might even visualize how good I will feel eating something healthier. All of this involves self-regulation.

Many executive functioning skills are at work in this scenario.  I have to be aware that I'm in this dilemma and that I'm having this urge. I have to inhibit that emotional response or thought of, "Oh my gosh, that cookie would go perfectly with my latte, and I want it." I have to redirect my attention away from that display case. I have to look at my phone and manage my attention accordingly. I need to talk to myself and visualize the future and what outcomes might be most helpful. That's a lot of working memory. I am also brainstorming different ways to cope with my urge and thinking of different things I could do. I need to organize myself and problem-solve.  

To identify self-regulation or executive functioning skills systematically, I recommend information-gathering with parents, teachers, and other people who work with the student. There are also some normed questionnaires, such as the BRIEF-2, the CEFI, and the BDEFS-CA, that can give a sense of impairment or show where the biggest challenges are. They all range from age 5-18.

There are also some informal checklists, such as the Executive Skills Self-Assessment (in Hansen, 2013), that targets executive functioning skills in teenagers. It has a nice, brief self-report inventory.  It asks different questions about how true something is for that teenager, then groups those questions into specific skills that may need to be addressed. 

Evidence-Based Strategies

Overview

Regarding ADHD treatment, medication is the primary recommendation for children, which is often not what people want to hear. I'm definitely not a pill-pusher by any means. I'm a psychologist, and I do therapy. But because of those brain-based differences, medication can be such a game-changer in addressing that biological piece. It can be a critical part of treatment, but it's not the end all be all. Research consistently shows medication can provide some benefit.  Behavioral approaches and targeting skills can provide some benefit as well. But if medication is combined with behavior therapy, that is where we see the most benefit for most individuals with ADHD.

When it comes to behavioral supports, there are two categories. One category focuses on the environment, and the other focuses on the individual. Environmental supports are behavioral therapy approaches that typically involve parents or the school. We are structuring the environment so that the child can be successful because of how their brain develops and how it works.

With the individual-focused category, there is evidence for some of those CBT approaches to treat ADHD-related challenges. Again, it's most helpful to think about ADHD difficulties as a performance deficit, not a knowledge or a skill deficit. Often a child with ADHD can understand what they need to do or what something means, but they struggle to perform it. They just can't do it in the moment because their attention is hard to regulate; they're easily distracted and can't inhibit their impulses. This is key for intervening effectively and appropriately and understanding what's difficult, when, and why.

Consider looking at different inconsistencies to determine where there's a skill deficit versus a performance deficit. For example, maybe a child can organize his backpack really well but has a disastrous desk. Is it because he doesn't know what being organized looks like or what it means? Probably not. He can probably describe a clean desk as having pens in a pouch and papers stacked up neatly. The student has the knowledge but can't put it into action. Maybe the classroom only does desk cleanings once a month, so he's left to his own devices to implement strategies. At the end of the day, he can't perform it even though he understands it. But he can keep his backpack organized. Why is that? It might be because the child's parent works with him daily and reminds him where things belong. They've color-coded and labeled everything and put a system in place to help him keep up with it. So, the environment becomes key to providing social supports where those problems exist.

Strategy 1: Instruction/Task Delivery

The first environmental strategy is how you present instructions or tasks to the child. There are hallmark symptoms of difficulty paying attention to details and keeping attention. Our instructions need to be simple and to the point. The fewer words, the better.  If it's too lengthy or wordy, we will lose the child's attention. 

The visual piece is also key. By having something visual, it takes what would load onto the frontal lobe, or working memory, and puts it in the real world.  

How we present commands is also important to consider.  It can impact how likely the child is to listen and understand. Here are some examples of what NOT to do:

• "Let's" commands  - These are unclear, tell the child that you will help and that the two of you are doing the task together. Instead, make those commands very clear in terms of what's expected, "You need to pick up your plate" or "Please grab that toy." Not, "Let's do it."
• Vague commands - "Stop it." "Be good." That's short and sweet but very unclear for the child. Instead, remove any need to think or pay more attention and say exactly what you want, "Place your hands in your lap" or "Walk slowly with me." Make it specific.
• Chain commands - If you tell a child with ADHD, "All right, go upstairs, take a shower, brush your teeth, grab that laundry and throw it down to me, then put on your pajamas and start to read before bed," they might get as far as the stairs.  These tasks must be broken down into at least one or two steps.
• Buried commands - Again, thinking about their attention, we don't want to bury our instructions.  For example, we don't want to say, "It's going to rain today. The forecast is calling for a lot of storms, so please put on your coat, or you might get wet and track water into the house, and it will be a mess." It's okay to have long conversations or to elaborate, but when giving an instruction or an expectation, get straight to the point. Give one small detail, such as, "Put on your coat; we're leaving."

Also, check for remembering. It can be helpful to have the child repeat the direction back to you so you know they were attending and listening. However, just because they can repeat it back to you doesn't mean they can do it. Be sure to follow some of the other strategies that were discussed previously. 

Another strategy that can help youth with ADHD initiate the next task, shift attention, manage emotions, and be flexible is to give warnings for transitions versus shifting focus abruptly. For example, if we play a card game in a therapy session, instead of suddenly saying,  "Okay, time to stop. We have to get back to practicing our coping skills," I'm going to give a reminder at the start of the session, "Remember we have a short break, and then we get back to work." As we approach the transition, say, "Remember, three more minutes until 45." The transition may not go perfectly, but it does make it easier for the child the more we can warn about those transitions.

Strategy 2: Externalize Information

I mentioned this earlier, but externalizing information and having many visual cues are great ways for the child to access the steps or the details they need without depending on their working memory. This is great for homework time, routines, different rules or expectations at school, tasks that must be completed, notes with reminders, or anything that involves a certain amount of time.

We can also use a timer as a visual.  ADHD can be thought of as a "nearsightedness" with time or time blindness. It can be thought of as a time disability.  Children with ADHD often don't use that internal clock to manage their behavior and to organize. We want to incorporate learning or experiencing how long tasks take or how much time has passed. When it comes to time and timers, we can practice that with them.  For example, "Let's see how long it takes to walk to the mailbox and back. We'll time it every day and learn how many minutes that takes." Being able to estimate time helps with learning to plan and complete tasks efficiently and effectively.

Visual schedules are also great. It can be very helpful for children with ADHD to have proportional blocks of time. If I'm showing that first, we have school and then we have soccer practice, but we know that school is six hours and soccer practice is one hour, we want to make activities visually proportional to the amount of time spent doing them versus the same size.

Visuals should be appealing.  We may need to revamp them or use new ones more often for children with ADHD than other children.  We want to capture their attention in the moment versus blending in the background. So think about changing photos or letting a child pick a new visual or a new font so that it continues to be exciting and relevant for them.

Strategy 3: Swift, Frequent, & Potent

This next strategy is related to the time disability concept.  We want to decrease the time between when something happens, how we respond to it, and the outcome. We want it to be swift. We want to act quickly and often with children with ADHD. 

Regarding immediacy, we want the correction or praise to be given right after the behavior occurs.  Delays of any kind make it less effective for children with ADHD. This applies to giving rewards or punishment. If the behavior happened 10 minutes ago, it may well have been last year. The connection is not there. 

Frequency is the idea of giving more praise for tasks that seem simple or that children without ADHD can do without much effort.  Also, a child with ADHD will have the urge or impulse to do something else, especially if what's expected is unrewarding or tedious. So think about frequency and give positive feedback throughout a task, not just at the end of it.

Finally, there is potency. I mentioned earlier that we compete with the environment for the child's attention and ability to regulate. Anything that's implemented has to be prominent and stand out. Reinforcers have to be more powerful. The same is true with punishment. We need to think about how we can increase the strength of a reward. We might have to change that formula, especially when considering potency. Children with ADHD habituate much quicker to rewards. Many people will say, "Oh, that's not really working anymore." However, we can keep the system and the rewards but change the potency. Think about changing it and making it more potent or interesting for them. 

Strategy 4: Resource Replenishment

The frontal lobe, which houses executive functioning abilities, requires a lot of mental resources and effort within the brain. It's like water in a reservoir or in a glass. When we're using our executive functioning skills, that resource is exhaustible, there's only so much in the cup, and it's going to drain.  Different tasks are going to drain that cup quicker.  If it's something more difficult, lengthy, or boring, that water will drain faster. For children with ADHD, that cup is much smaller because of their developmental delay, and it often empties quicker.

This is where replenishing is key. We can replenish with routine physical exercise and movement. We don't want schools using recess as a punishment and removing it. That is a refuel time. We can replenish during executive-functioning loaded tasks. When a lot of sustained effort or persistence is required, or something is long, these children need breaks during that task. They can be brief, but they'll need them during and after, with rewards along the way.

Strategy 5: Facilitate “Social Economy”

Another key strategy is what I call "social economy." We want to promote positive social opportunities and successes for these children. They can exhibit poor social behavior or be viewed negatively by peers because of their difficulties. For example, there are studies in which a peer is told, "Oh, this kid has ADHD," when that is not true (the experimenters are just saying that), and they proceed to play and interact with that child differently and more negatively than if the peer was not told the child had ADHD. So, it's important that peers see this child with ADHD in a positive way. 

The way we can do that for them is to plan and structure opportunities for success.  At home, have structured play dates where you're setting limits on activities that they can or can't do. You're making it more formal versus just running around and playing. Maybe you're doing a science experiment or a craft. These children need that one-on-one at first to succeed with a peer, and then you can slowly add more children.

They're probably going to need more adult check-ins or facilitating appropriate behaviors. Social interactions and opportunities might have to be shorter at first. We want to ensure they are going well and smoothly; then, we can increase the length of time or the number of people.

Also, keep in mind what the goal is. Is it simply for them to have a friend over? Then, focus on that and not correct a bunch of other behaviors. Ways this can look at school is giving the child special jobs that their peers see them doing well and getting a lot of positive attention. It can be earning privileges for the class. For example, maybe one of their rewards is the class gets a bonus recess. That can facilitate a positive economy for that student. And remember, it is common for children to misunderstand or misuse the ADHD label. We have to make sure peers are educated on neurodiversity so that there is acceptance and receptiveness to those differences.

Strategy 6: Social Behavior Skill Training

Research suggests that social skill training can be very effective. But a key piece is promoting generalizing. How do we do that? We give direct instruction on a social skill, rehearse it, coach the child directly, and then give feedback. Social skills are like making conversations or sharing how we follow along with rules during a game, or take turns.  Working on that in a session is helpful, but we must focus on generalization. Oftentimes, there is this train-and-hope philosophy of the child learning the correct thing to do, and now they will go do it.  But they can't enact it well because they're not self-monitoring in that moment. They can't regulate their impulses, so they need an adult or a parent to coach them and promote their successful use of it. Plus, those adults are more likely to be in naturally occurring situations. We can do social skills training to generalize by coordinating across settings and with different adults to reinforce the skill.

Here is a sample practice sheet that I might have a child take outside of a session. Maybe we're focusing on back-and-forth conversations, so we practice building a conversation together, like building a tower. So I will have them practice it. I will have them notice situations, and the parents will help them monitor them and become more aware.

Strategy 7: Organizational Skills Training

Difficulty with organizational skills becomes prominent around third grade, and then it persists. Third grade has a curriculum where students are expected to be much more independent. So early intervention, particularly before middle school, becomes key because we know as students advance into middle school, there are many more demands on organizational skills. They have numerous classes or homework and less adult supervision.

Similar to social skills training, there's a lot of direct instruction in organizational skills. You're rehearsing and coaching the child in the moment. Tracking tasks is a good example. How do I record my assignments? How do I manage materials or time? What are some ways to organize my room or my binder? 

We can teach them to track how long tasks take or plan what to do first, second, third.  We can teach them how to break tasks into steps and monitor progress. We are working on these organizational skills in a clear, direct way. There are numerous great curriculums available for organizational skills training.

It will be important to incorporate rewards. Learning organizational skills is hard, so using the system or starting to learn steps will be important when focusing on this with a child with ADHD. And as always, we're scaffolding. So the adults are present and engaged while helping the child build and maintain that system.

A few more examples include a child who is having difficulty turning in their homework. I want to think through all of the steps involved in that and what skills we want the child to develop.  Is it writing it down in their notebook or bringing home the right materials? Another example here is a teenager who is working on organizing their room. We want to think about the steps it takes to clean and organize that space. 

All of these examples are based on some organizational skill training workbooks or materials that are included in the resources.  

Summary

My goal with this course was to describe what ADHD is, including common symptoms. Explain brain-based differences between children with ADHD and their neurotypical peers, including common myths. Identify strength areas and support areas. And discuss how to implement practical, evidence-based strategies that promote self-regulation by adapting the environment and working with the child directly.

Questions and Answers

Do you think ADHD in adolescence is overdiagnosed?

That's a hard question because I think right now is a time when we're becoming more aware of it. But I will add that often, ADHD can be misidentified. So just because a child is distracted doesn't mean they have ADHD. Many kids with anxiety, for example, are highly distracted. They're thinking about things that could go wrong or trying to monitor themselves, and they're thinking about it and worrying. So we know anxiety can affect executive functioning and attention.  So, I think it can definitely be misdiagnosed if we just assume a child who's inattentive must have ADHD. That's where getting a comprehensive evaluation, a comprehensive neuropsych evaluation or psychoeducational eval is such an important piece before we just jump to conclusions.

Does positive or negative reinforcement work for children with ADHD, or is ADHD something a young child, like a second grader, wouldn't be able to control?

It's a balance. We don't want to expect a behavior that the child cannot, but we do want to promote a behavior for success. So a lot of that brings me back to this expectation I have for this second grader.  Are my expectations based on another second grader who doesn't have ADHD, and I'm setting the bar too high?  If so, that will be impossible for the child with ADHD to reach because of those neurodevelopmental differences. Or am I thinking about something the child needs to do to succeed and steps we can reinforce and promote to make that happen? So, it varies on the individual case, but, often, we need to ensure that our expectations are realistic. We also have to ask if the environment makes it possible. I think that becomes a huge question. I'm expecting this kid to regulate their emotions, but if I have an environment that's overwhelming their executive functioning skills, they won't be able to regulate that emotion.

Do you have recommendations regarding school or homework skills like organizing spaces?

I do. There is an organizational workbook listed in the references. I would highly recommend looking for anything that's described as organizational skills training. That is very evidence-based.  I'm not promoting certain material, but this is a really great curriculum that talks about different trainings and skills and helps to break them down into steps.

How do you teach neurodiversity in the classroom?

There are a lot of great children's books, especially for younger students, that are wonderful at illustrating what strength lies in diversity and what it means, and what it doesn't mean. They are written in a way that's accessible for children too. Often in the classroom, I recommend that teachers include them in their curriculum. Have that be the story time, have that be the topic, without singling out a specific child if the child doesn't want to share that about themselves. These stories are a great way to create an environment of understanding and acceptance. Videos that explain what ADHD is are great resources too.  There's a really good one on YouTube that is cartoon-style, and it's a child explaining to another child that they have ADHD, here's what it is, and here's what it means. 

References

American Psychiatric Association (APA). (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Barkley, R. A. (2022). Improving clinical diagnosis using the executive functioning—self-regulation theory of ADHD. The ADHD Report, 30(1), 1-9.

Barkley, R. A. (Ed.). (2018). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (Fourth edition). Guilford Publications.

Connaughton, M., Whelan, R., O'Hanlon, E., & McGrath, J. (2022). White matter microstructure in children and adolescents with ADHD. NeuroImage: Clinical, 102957.

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current concepts and treatments in children and adolescents. Neuropediatrics, 51(05), 315-335.

Gallagher, R., Abikoff, H.B., & Spira, E.G. (2014) Organizational skills training for children with ADHD. The Guilford Press.

Hansen, S. (2013). The executive functioning workbook for teens. Instant Help Books.

Miller, K. (2018). Thriving with ADHD: workbook for kids. Althea Press.

Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J. P., Greenstein, D. E. E. A., ... & Rapoport, J. L. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the national academy of sciences, 104(49), 19649-19654.

Tourjman, V., Louis-Nascan, G., Ahmed, G., DuBow, A., Côté, H., Daly, N., & Sadek, J. (2022). Psychosocial interventions for attention deficit/hyperactivity disorder: A systematic review and meta-analysis by the CADDRA guidelines work GROUP. Brain sciences, 12(8), 1023.