Podcast Transcript
Understanding Health Disparities and Improving the Provision of Effective ADHD Treatment in Underserved Communities
Summary: Effectively treating children with ADHD in Black and Brown communities begins with education on the disorder for individual families. Becoming familiar with, and when possible, part of the communities you serve will help you to better meet the needs of your patients and their families. Psychiatrist Napoleon Higgins, Jr., discusses ways to meet families of color where they are and how to develop cultural competency to improve your healthcare practice.
Very often the situation a person is born into plays a determining role in the type and quality of healthcare they will receive. Medical professionals who listen to their patients’ concerns and include family members in treatment coordination; who take the time to educate patients, parents, and extended family members about ADHD; and who actively employ the language of the community they serve can improve long-term outcomes for their patients in diverse communities.
Max Wiznitzer, MD
Max Wiznitzer, MD, is a pediatric neurologist at Rainbow Babies & Children’s Hospital in Cleveland, OH. He is a professor of pediatrics and neurology at Case Western Reserve University. He has a longstanding interest in neurodevelopmental disabilities, especially attention deficit hyperactivity disorder and autism, and has been involved in local, state and national committees and initiatives, including autism treatment research, Ohio autism service guidelines, autism screening, and early identification of developmental disabilities. He is on the editorial board of Lancet Neurology and Journal of Child Neurology and lectures nationally and internationally about various neurodevelopmental disabilities.
Napoleon Higgins, MD
Napoleon Higgins, MD, is a child, adolescent, and adult psychiatrist in Houston, Texas, and the owner of Bay Pointe Behavioral Health Services and South East Houston Research Group. Dr. Higgins also serves as the executive director of Black Psychiatrists of America and CEO of Global Health Psychiatry. He is the author and coauthor of multiple books on ADHD, depression and grief, Black mental health, and physician practice issues. He specializes in nutrition and health to improve the lives of his patients mentally and physically.
Learning objectives:
- Describe health disparities and cultural beliefs in underserved communities that can impact ADHD diagnosis and treatment
- Describe co-existing conditions in people with ADHD
- Explain the considerations of effective ADHD medication management in underserved communities
- Explain the importance of integrating behavioral and other interventions for people with ADHD in underserved communities
Announcer: You are listening to Pocket MD: Training on ADHD in Children and Adults.
Dr. Max Wiznitzer: Welcome to the podcast. I am Dr. Max Wiznitzer, co-chair of the professional advisory board of CHADD, and our guest today is Dr. Napoleon Higgins. Dr. Higgins, please introduce yourself to our audience.
Dr. Napoleon Higgins: Hello, my name is Dr. Napoleon Higgins, and I am a psychiatrist in the Houston area. I do child, adolescent, and adult psychiatry. I love working in this ADHD space. I'm in private practice. I also do some clinical trials, as well. So, it's great to be here to discuss ADHD.
Dr. Max Wiznitzer: The goal of this podcast is to discuss the issue of health discrepancies for the underserved population. So, to start with, would you please explain to our listeners what are health disparities and how do they impact the underserved communities?
Dr. Napoleon Higgins: Health disparities are disparities in outcome, disparities in care, disparities in delivery. Many times when you look in the community, when you look at the Black community specifically, you see a very large underserved population. That is multifactorial, why you have that. You have issues of less likely to be insured, more poverty, issues of delivery and access to care, misunderstanding of healthcare issues, and then the issue of disparities in treatment, where many times African Americans can be in a situation where they're not as likely to receive the same treatments as whites do in the country, and so these are disparities that actually lead to poor outcomes and even actual death.
Dr. Max Wiznitzer: Well, let's look at some of those points that you raised. What are some of the cultural beliefs in the African American and underserved communities that basically act as barriers to receiving effective healthcare?
Dr. Napoleon Higgins: There's a very large mistrust in the community, based upon the historical nature of the country and how it was founded, in the issue of slavery, the issue of post-slavery and Jim Crow, civil rights movements, and all these different movements that we've had up until this point. And when you look at the numbers, and it's not an issue of stacking opinions, but when you stack the numbers and you look at delivery of care, there are disparities that are seen there that need to be addressed. So, especially with these things going into electronic formats, you can actually run the numbers quite easily and see these disparities and outcomes.
So, we have to get through the issue of mistrust, but also the issue of poor education, health education, and poor mental health education. Too often, we're not having these conversations in other communities that need them. So, a lot of people are stuck in a situation where they are afraid, they don't know where to go, they don't know if they'll be treated kindly by the system itself, the healthcare system, and then they stay away.
Sadly, a lot of individuals wind up functioning poorly or having the consequences of [lack of] mental healthcare to impact them, when it does not have to be that way. So, it's going to be very important for us to make sure that we're educating individuals, that we're establishing situations in the community where we're there not just for one talk or one presence, but where we are embedded in the community so they can have us as a trusted source.
Dr. Max Wiznitzer: Can you expand on the last statement? In other words, you've identified what some of the core issues are. How do we remedy them, and how can either the individual practitioner remedy that or a health system remedy that issue?
Dr. Napoleon Higgins: It is multifactorial. One, I'll start off where I left off, embedding yourself in the community. Too often, we'll have where, I would say, there's a clinic. It's in the community and people come to the clinic, but outside of the clinic, are we actually going to the other places to spread the knowledge and information? Are we going to the churches? Are we going to the schools? Are we going to the mosques? Are we going to the temples? Are we going to the community events? Do they see us there? Because that's where the relationships are established. And too often, they have to come to us in our situation, versus actually seeing individuals in their situations.
But then also, as the individual clinician, we need to educate ourselves about other people's culture. The life of the world is not centered around us as individuals or us as a group. There are a lot of “usses,” if I may use that term, out there. And as a psychiatrist and as a mental health professional, we definitely want to be social scientists. We want to know how people think, how they live, how they see things, and too often, we can see it as a paternalistic standpoint of it must be done this particular way. And too often, a lot of cultures, a lot of places, have other coping strategies that we expect for them to abandon in order to join us in what we say or what we need to do.
On an institutional level, we need a lot more cultural training. Do the people who are serving the community understand the community and the actual needs of the community—and what the community wants? So, not only do we need to take treatment from an individual standpoint so far as what are the wishes that the individual has, but also, what are the wishes that the community has? And building our institutions based upon that, versus what we are seeing that we feel like the community needs. What does the community want and need from us?
Dr. Max Wiznitzer: Could you please give us some examples of these wishes or beliefs or the cultural beliefs that impact the understanding of ADHD in these communities?
Dr. Napoleon Higgins: You look at cultural beliefs, and there's an issue of mistrust. Bad information can go out. The thought that these medications are a form of mind control. They're trying to change the minds of how our little Black boys think, and that we're introducing people to substances like cocaine, to get kids hooked on drugs early. This information goes out there, and it's important to make sure that we address these issues in the room.
The question is, after I've made the diagnosis or as I'm making the diagnosis, looking at what the issues are, how would you like for us to help you? What can I do to help? And giving individuals options and knowledge and information is where we definitely want to start. One, us, doing our part in embedding ourselves and coming up with a treatment plan that the patient and family agrees with. But as institutions, so when we're looking at institutions, the institutions have to look at the issue of their cultural beliefs, and what are the beliefs of the community?
So often, we'll believe that in our institutions that this is the way it should be done, and we don't take into the point or into the thought of what the community is looking for and what the community needs. So, actually having a good conversation with the community leaders, with those who want the information, to make sure that we're doing those steps as well, and that it's not just this is what's best for you and this is how it's going to be done. It's how can we join in a partnership to make mental health and to treat ADHD in the community?
Dr. Max Wiznitzer: Are you aware of any culturally sensitive diagnostic tools for ADHD that are available to providers?
Dr. Napoleon Higgins: I do not know of a single culturally specific diagnostic tool for ADHD other than the one I'm currently working on right now.
Dr. Max Wiznitzer: What would you put in a tool in order to basically reflect the issues that you have discussed?
Dr. Napoleon Higgins: I would put in the tool, how do families and how do patients and caregivers see ADHD in their own words? When we look at the diagnosis of ADHD, and say, we use the "psychiatry bible," and I'll put that in air quotation marks, we're looking at the DSM-5-TR or whichever version comes out next. If a person reads that book and tries to understand their diagnosis, most lay individuals will not be able to understand what is written in the book itself.
So, what I would say is, I would start from the community standpoint: All right, your child has been diagnosed with ADHD. What do you see that are the issues that need to be improved with what is going on with the phenomenon of the child? Using the community's own words, versus us putting our words into the community, having the community use their own words for those individuals impacted with the diagnosis is a good place to start. Because many times, people disagree with the diagnosis because the language is not similar to how they would describe the symptoms.
Dr. Max Wiznitzer: What are some of the conditions that might mimic ADHD, but are not exactly ADHD, that you see in these communities?
Dr. Napoleon Higgins: One of the biggest issues that I think is missed, especially in minority and underserved communities, is the issue of trauma. I see a lot of undiagnosed trauma in children, or sometimes, you did ask the question during the interview, but now that I've been around treating long enough, I'll have kids, who are now adults, who will tell me that they were dealing with trauma when I was seeing them at an earlier age.
Now, on all of my initial evaluations, I have a questionnaire about trauma. There's questions about trauma for everyone who comes in. And the response was, "No, I don't have any trauma. No physical, no sexual, no, I don't have any emotional abuse or things of that sort." But then fifteen years later, now that I'm seeing you, now you're thirty years of age, there's an issue of trauma that was going on that was undiagnosed—community trauma, so far as violence, shootings, deaths, issues of racism. I'll ask kids, I always typically ask, especially someone of color, any issues of culture and race. They say, "None other than being a Black kid growing up in America."
And it's like, well, there's a certain level of anxiety and trauma that comes along with that, with what is going on in the country. And the wording that we're hearing and the rhetoric that is kicked up, especially over, say, the last five to ten years in America, there are certain things that are being said in schools that were just not said, at least openly, that you’re hearing now, that I’m hearing kids report now.
So I would say a lot of issues of trauma, a lot of issues of—you have to look out for issues of poverty and how that impacts overall mental health care and treatment. Issues of access to services are going to be an issue. So, we have to look at, there are a lot of things that look like ADHD that are not ADHD. And just because a kid is inattentive, that does not mean that they're ADHD. If they are ADHD, that does not mean that you've treated the entire child or even the entire adult. We have to look for all the comorbid issues that are occurring as well.
Dr. Max Wiznitzer: Some of those factors you identified before, are they really limited to certain socioeconomic groups, or are they more ubiquitous?
Dr. Napoleon Higgins: I would definitely say they're ubiquitous, like the less money that you have, the more you are impacted. We used to have a news commentator in Houston by the name of Marvin Zindler, who's passed away, and his catchphrase was, "It's hell to be poor." So, the lack of resources; so, there's an issue of a problem that happens throughout all communities, but when you lack the resources or lack the information, it could be very difficult to overcome those issues. And that's where we get into the social determinants of health. Where you're born, who you're born to, and what situation you were born in, actually determine what the outcome so often will be.
Dr. Max Wiznitzer: What would you tell a clinician in order for them to provide successful ADHD treatment for members of underserved communities? What should they specifically do?
Dr. Napoleon Higgins: I would say, when looking at underserved communities, the first thing is to understand the community. Understand the community needs, have an actual understanding, compassion, understand the culture. If you're really, truly interested, embed yourself in the community itself. Obviously, our lives are very busy, we have a lot of things to do, but I think too often we believe that just showing up at the moment in time of the appointment is enough. And really what you want to do is understand that community more.
If I'm working with the group of whatever demographic and I know that I'm about to start, I'm going to start working with them often, I'm going to go read about it. You've got to be a curious person. If you're going to start doing college mental health and you never worked on a college campus, I highly recommend that you start reading a lot about college mental health.
Or, if I'm looking at the issue of working with a demographic that I don't normally work with, I actually find it to be interesting to learn more about that demographic and have passion about learning about them. Because the fact is that I want to be an adequate healthcare provider for whatever group that I'm dealing with.
And if it's something that I just thought I knew, because realizing that everybody's not the same, I'm Black in America with my own experience of being a Black American, which is not the same as every Black American. What if you are a recent immigrant as a Black American? What if you grew up in a different part of the country, maybe a different socioeconomic status? If I'm going to be highly embedded in that group, it is of my interest as a psychiatrist to know who I'm speaking to and know what the concerns are.
And I think too often we assume that what we know is correct and how we say to do it is the best way that it can be done. And that can be very off-putting, when the doctor is not listening to the individual's needs and finding places where we can meet halfway, or sometimes I need to go more of the way and sometimes the patient needs to go more of the way as well, so that we can have the best outcome that we can look for.
Dr. Max Wiznitzer: Thank you. In the communities, what is the perception and acceptance of some of the interventions that we do for ADHD? Let's start with behavioral interventions.
Dr. Napoleon Higgins: Honestly, I think behavioral interventions, assuming they're not punitive, one of the most common ways, especially in the Black community, people are looking for, what can I do to get this better? Also, we need to change perceptions. So often I'll find families where their child will have ADHD, and they feel as if they failed the child or it's something that they have done wrong. So, we want to make sure that we work on perceptions.
And when it comes to behavioral interventions, going over those things, oddly enough, is probably more where the Black community wants to be. Now, there's also medication intervention, which tends to be the biggest issue, where individuals don't want to take medication, and the fear of medication, a lot of that comes from a lack of understanding on what the medication is supposed to do and how it's supposed to work.
Another important thing to consider when you're looking at diverse communities—too often in psychiatry, we look at the individual and what the individual needs are, and then also how do we treat the individual with medications. The fact is that treating ADHD is so much bigger than medications, but also in other communities, there's the collective. So, not only are you treating the child many times, but you're also treating the parent and the issues that need to occur there so far as behavioral interventions, and also the expectations of what are the symptoms of ADHD, what are we expecting to get better, and what is the benefit of that?
And then, I want to step a little bit further outside of the room and make mention of [the fact that] sometimes the person making the decision about the child in treatment is not in the room itself. That could be the other parent, especially if the family is divorced, or that could be an elder, the grandmother, or someone at the church. There's a larger collective that is impacted and that is consulted than just the people inside of the room.
So, when you're looking at an issue of noncompliance or a lack of following the treatment plan, be inquisitive. Ask the question, What is the particular issue that I'm missing here, so that I can help you all work through this? And I tell people, if they say, well, their grandmother said that she doesn't want to give them the medication, then I'm like, "All right, I'll tell you, why don't we have the grandmother to come into the room?"
Or, "We've set up a set of rules in my house, his dad doesn't follow those same rules, and things fall behind and we have 50/50 custody." We need the dad and the stepmom in the room as well so that we can go over these things, understanding that it's not always the individual, but there may be a collective going on when it comes to improving outcomes in treatment.
Dr. Max Wiznitzer: Are there barriers to accessing the behavioral interventions for ADHD? In other words, is it easy? Are the resources there in order to do it?
Dr. Napoleon Higgins: When you look at the issue of resources, you have to look at the issue of, one, insurance coverage and realizing that still you have a quarter to a third of Black Americans who do not have insurance coverage. So, despite the movement with ACA, despite the healthcare exchange being expanded and more Black people are covered with this, also, you still have a lot of Black people who are not covered within that. So one, access to services, access to care. The issue of copays and deductibles and all that become an issue.
And even for your families who do have insurance or professional families, a lot of families cannot take the time off work. Once a week, I'm supposed to pick up my kid from school, drive over here, miss work, drive them back to school. A lot of families do not. It takes a fairly high-paying job with really good benefits, and normally you're probably mid-management or an executive to be able to take that type of time off, to do behavioral therapy. So one, access to behavioral therapy from an insurance standpoint and from a financial standpoint, but also being able to access that type of intense, I wouldn't even call it intense care, having the time to access that adequate care during the week can be very problematic for families.
Dr. Max Wiznitzer: What about placing the therapy programs within the school setting so that the children can access it? Is that something that is frequently done, and is it successful?
Dr. Napoleon Higgins: When it comes to behavioral therapy in school, no. That is not normally going to be very accessible, not unless there's some sort of grant or funding putting the therapist into the school. Too often your school counselors are overwhelmed and overburdened. I know my mother, God rest her soul, was a school counselor, and at her elementary school they had at least two and sometimes three school counselors. Now, you have schools that are sharing school counselors. So, even though you do have a person who's trained as a mental health clinician inside of every school, or at least somebody who's accessible, too often that person does not have that kind of time during the day.
School counselors are now moreso people who do schedules, they're in charge of the testing, sometimes they're in charge of teaching classes. Too often the school does not take behavioral intervention seriously. Therefore, if there's another hour, we do it for school enrichment so far as math or science or passing whatever standardized exam or test. Too often, that is difficult to access in schools.
Now, I did once work with a grant that did that type of work, and the intervention was very successful, being able to meet an individual in their community, having mental health professionals and clinicians actually inside the school. And it's fairly evident that the outcomes are better whenever a person can access the services easily.
Dr. Max Wiznitzer: How can a provider help underserved communities, especially parents, be more involved in the understanding of some of these behavioral therapies, like cognitive behavioral therapy or positive parenting strategies, the specific provider who may be making the recommendations?
Dr. Napoleon Higgins: I know for myself, I do have a referral list of providers in the area who do that type of work. Now, so often as a psychiatrist, I only have a certain amount of time in the room, and my specialty is medicine, so far as I'm a medical doctor and I do medical things. Now, even though I'm trained in much of that, there are so many other people who do this work on a regular basis who are extremely effective that I've got to use these ancillary services to actually do my part so that other people can do their part, as well.
Dr. Max Wiznitzer: Do you have any resources you share with families so they can understand the benefits of the behavioral interventions?
Dr. Napoleon Higgins: In fact, I do. I have a book about it. It's called How Amari Learned to Love School Again: A Story About ADHD. It is about a young man who is very excited about school and he's doing well, but all of a sudden he starts to have difficulties and troubles. And in there, inside of the storyline are the behavioral interventions, so far as making sure that one, the family is on board and communicating well; two, making sure that the school is on board, improving communication with school, seeing a behavioral therapist, and letting the child know, charts, sitting in front of the class, knowing to raise his hand, staying in constant communication, learning how to put the reward system first, realizing that there's always something the kid enjoys doing.
And too often when there's a punishment, we end up taking something they love away in order to get a desired effect. I say, no, no, you don't want to do that. What you want to do is make the carrot bigger. All right, if you do this, this, and this, then you can play basketball all day Saturday, if your grades are up and you're doing well and you do all your chores before you go out to the court. So essentially, you put the behavioral intervention as part of the reward system itself. You don't want to take away what is working, what the child loves. What you want to do is make sure that you incorporate that into what we're doing.
So, these behavioral interventions are oddly something that I believe are well taken, but we also have to pay attention to [the fact that] not everybody in every home is the same. So, if you've got a parent, so often in Black families, about 70% are going to be single family homes, with 90% of those being women. So if you have a woman who has a three-year-old, an eight-year-old, and a twelve-year-old, one or two of them have ADHD, she's working two jobs, and she doesn't have a whole lot of time to get some of these other things done, too often we say that the parent is not compliant or the parent is not concerning.
No, the parent is trying to pay the house note or the rent and put food on the table while working, and then we're having a cousin or somebody looking after the kids when they get home from school. Some of those interventions that can be very good may not be as successful as we would expect. So, we are trying to figure out where are we at, what can we do with the time that we have, and to make sure that we're taking those other things into understanding and that every home is not the same.
Dr. Max Wiznitzer: What do you do when families basically are in denial about the presence of ADHD in the child? How do you work with them in order to get them to accept, acknowledge, and intervene for the diagnosis?
Dr. Napoleon Higgins: The thought is you educate, you educate, you educate, realizing that you cannot always convince everyone to receive care and treatment. So, what I try to do is understand Why are we in denial? What are your fears? What are your concerns? What am I not communicating? What can I do better? And find out also, What are your needs? Obviously you're here in front of me. What is it that you came in here looking for? Were you sent here because, I don't know, the school said the kid couldn't come back until they saw a psychiatrist? What is going on that made them make that type of decision?
And trying to see it from the parent's standpoint, from the parent's eyes, because too often when we send a kid in for care or treatment, especially when it was pushed upon them, a lot of times they can see the clinician as part of the punishment, not necessarily where we go to get help, but essentially, you're part of the program that is now affecting my child.
So that can be some barriers up. I say this jokingly, but it's true. I'll see anybody at least once. Now it may be mutual in that we may not come back, but it's not a situation necessarily about myself. It's a situation where maybe I can't get through to the individual, but what I can do is share as much as I can in the time that we have. Because sometimes the light doesn't come on at the time. Sometimes there's just things to think about. The light may come on later.
So don't get disappointed. There may be a lot of issues, and the problems of denial are multifactorial. It's never one thing. Try to help identify the elephant in the room, but also sometimes for individuals, it's not time to talk about it. And you've got to be able to respect that from a family or from whomever you're dealing with, that right now they're not ready to hear it. But try to give them as much information as possible.
And as I talked about, I know in that book, Amari Learns to Love School Again: A Story About ADHD is that the characters are all Black, the majority of the characters are Black. And we use the name Amari because it's a common Black name, and we use Black faces with Black hairdos and Black cultural pictures and things of that sort to help people be able to buy in. Now, the fact is that the book is good if you're Black, White, Hispanic or whatever you might be. But the point is that you try to give individuals access points where they can identify with the story.
Dr. Max Wiznitzer: And I assume you also leave the door open, that even if people don't accept what you're saying then, but because you said they may think about it and consider it and in the future say that this is something I want to do, you don't basically shut it and say, you never can come back.
Dr. Napoleon Higgins: No, no, no. For me to shut the door and say you never can come back means that something bad happened. There's a threat of physical violence. Other than that, there's no shutting the door. The door is always open to be received. And oddly enough, I've had, seeing that I've been doing this now for twenty years, I will have people come back ten years later and decide to receive diagnosis or treatment. Or sometimes the parent decided that you didn't need the medication, but then you became an adult, and then as an adult you decided, you know what? It's time to go ahead and receive medication and treatment and care for this particular diagnosis, and that my parent did not want me to take this when I was eighteen. But now that I'm twenty-five years of age, I'm out of the home, I went through college, I struggled my way through, and I heard what you were saying, even though my parent disagreed. Or sometimes the parents disagreed, maybe mom couldn't bring the child in for appointments, or they couldn't afford the medication, they didn't know how to say that. Or my mom wanted me on the medication, but my dad did not want me on the medication. And there are a lot of factors that go into why we never started care and treatment. So you want to share the information, give the person the opportunity, and you always leave the door open for care and treatment. You never shut the door.
Dr. Max Wiznitzer: There are statistics telling us that in underserved community, such as the African American community, that the diagnosis is delayed in comparison to other communities. What is the impact of this failure to diagnose and treat in a timely manner?
Dr. Napoleon Higgins: I tell people the school year is very short. So, the school year for a third grader is nine months. Now in the third grade, you're going to learn a lot of math. You're going to learn multiplication, division. Your writing skills have to improve. That is a very big grade. Of the nine months, you started third grade, you struggled in September, you struggled in October, the nine-week report card comes out in mid-October, sometime in November. You set an appointment to see the doctor. It takes two months to get in. Now you're looking at January. So now you've missed half of the school year of a very important grade, struggling with mental health issues and conditions.
Also, you set up a paradigm in the kid's brain where, essentially, I'm not good at school, I'm not able to learn. I am constantly getting into trouble. I'm always a problem, and I'm forced to be there every day, for eight hours a day. I'm forced to be at a place that I'm not comfortable, that I don't do well, I don't understand. I'm constantly getting in trouble. That sets up a very bad thinking and behavioral pattern inside of that child.
So, the need to get help is a need, to me, of immediacy, that we get this corrected, that we get better very soon. Now, the long-term consequences of struggling in school and having problems is the issue of incarceration. We successfully in this country made ADHD, a medical diagnosis, a criminal offense, because of the issue of punishment versus treatment that starts off very early, and then the consequences of that, of struggling in school, not being educated, getting into trouble, I'm a bad person. Now I'm with a group of kids who often get into trouble as well. Now we start to pick up bad habits, and it's hard to break those habits, especially once they hit the issue of adolescents, the age of adolescents, where you start to be influenced by the peers who are around you, which then sets up a bad outcome as an adult.
When we see this, we need to make interventions as early as possible. And too often, we wait. We say the kid is a bad kid. We'll call it a character issue versus a medical issue. And then the setup is in a completely different direction, when we delay that diagnosis because either resources weren't there, it wasn't identified, denial in the family, misunderstanding of the diagnosis, and then the issue of flat-out racism and punishment. This kid is a bad kid, he's a bad actor, he's not smart. And then we put that child into a situation where we've put them on a pathway of failure at a very young age, and that's something that we have to stop.
Dr. Max Wiznitzer: What percentage of incarcerated adults have a diagnosis of ADHD?
Dr. Napoleon Higgins: It is thought that up to about 70% of persons who are incarcerated have attention and impulsive disorders.
Dr. Max Wiznitzer: Is that percentage the same irrespective of which community you come from?
Dr. Napoleon Higgins: I would probably say so. Now when I say that if you're a person of color, you're more likely to be directed towards legal services versus receiving school services, but when you look at actual persons who are incarcerated, more white people are incarcerated in the United States than people of color.
Now, a higher percentage of Black people and a higher percentage of Hispanics are incarcerated than the general population, and less Whites are incarcerated than the general population. But because of sheer overall numbers, Whites are the largest group that are incarcerated. So well often, we can look at it as a Black or Brown issue, which it does impact the Black and Brown community more so. But the fact is that it impacts all communities. This issue of the school-to-prison pipeline hits us all.
Dr. Max Wiznitzer: When it comes to medication, what have you noticed and what data do we have? Tell us about adherence to taking medication in the underserved communities.
Dr. Napoleon Higgins: When it comes to the issue of adherence, I don't know actual numbers. I would guess possibly a little bit lower, but it's hard to say. And a lot of that comes with education about the diagnosis, misunderstandings, and mistrust. So, if you are not trusting of the doctor, you're not trusting of the system, I'm expecting that you're less likely to be adherent. Now the more educated you are, the more money that you make, the more resources that you have, the more likely you are to understand the diagnosis of ADHD, identify the diagnosis, and receive treatment and care.
I would guess social determinants of health, the higher you are on the socioeconomic scale, the more likely you are to engage in treatment and care. I've seen families, especially I'm looking at my suburban, upper middle class white families, who many times the parent brings the kid in for ADHD and basically read off to you all symptoms of ADHD. It's spelling out the DSM. It's a conversation in the community. It's a conversation in the family. We've accepted the diagnosis.
Versus, I'm more likely in my Black and Hispanic families to see that, even though I do, I do have Black and Hispanic families who are very well educated about ADHD, who are very engaged, but well too often it's an issue of I don't understand it, I disprove of it, I don't like it. I'm fearful of what is the consequences of the diagnosis. I'm fearful of the educational situation that goes on. I'm fearful of the school services. When they see the special education services, issues of fear. "I don't want my child to be in special education."
And I explain to them, there is a lot of money available to help your child and it is unlocked through special education services. And I also say whether your child is receiving remedial services or if your child is receiving gifted and talented services, that all goes through special education. And by having a child evaluated, tested, and receiving services, this actually gives your child an advantage. And what many families don't know, it may give your child an advantage over your regular education-type student.
Like, when you look at remedial services, your child needs to go to summer school because they fail to do well in whatever class. Oddly enough, if your child goes to summer school for that class, your child ends up ahead of his class going into the fall year. So, I said, "No, these are not services that you need to run from. These are services that you need to run to."
But the issue becomes the fear of labels and the fear of the country and the fear of what happens to people of minority races or ethnically diverse races that causes the family to be like, "Oh, no, no, no, not my child," because they've heard so many horror stories that can occur. But I say, "This is not the end of the story. This is the beginning of the story of how we get all these things better and we take advantage of everything that we have available to us."
Dr. Max Wiznitzer: How can providers educate and instill confidence in individuals with ADHD and their parents, in a way where the individuals and families do not feel like they failed? And what would be, if you want to think of, a few specifics of how to do that?
Dr. Napoleon Higgins: Well, I tell families that ADHD is not uncommon. This is a very common thing, one out of ten, some studies say as far as one out of twenty. And I tell individuals that it's a different way of learning. It's not necessarily a disease as more of some people learn differently. The problem, though, is that school is set up a particular way and they don't change all of school for your one child.
So essentially, if you're in the classroom and there are nineteen other kids and your one child is disruptive, they're not going to sacrifice the nineteen for your one child who can't sit still in the second grade. The other side of that is if your child's inattentive, they're not going to stop the way they do the education of the other nineteen for the one inattentive child. Oftentimes, often with children who are ADHD, they tend to be quick learners and have faster processes. So essentially if the teacher can get their attention one-on-one and give their information over the next five minutes, the kid may be all in and figure it out.
But the thing is that that class period is going to be done over thirty minutes, not in the first five. There's not one teacher with one kid, it's one teacher with twenty kids. And so now your child starts to struggle in the room. It has nothing to do with your child's ability to learn. It does not have anything to do with your child's IQ. It's just that your child is a different type of learner and the school situation is not advantageous for them. But with other services, they can actually learn and do well and do as well as anyone else. That may require some school interventions.
I was talking to a young man the other day, struggled with ADHD. Now he's working on his PhD, and he was struggling on his PhD, and I said, "Have you talked to them about accommodations?" And so he was like, "Nah, I don't think I find the need to do that," and whatever. He goes on another couple years and doesn't do it. Then finally he does, because he was having difficulty passing his licensing exam, which is standardized testing. You have to take the test over a long period of time. You have a long test with a whole lot of questions that you've got to get through, and he was not able to demonstrate what he knew on the exam. I think it was a professor who recommended that, "Listen, there's a huge discrepancy in your work and what your value to us as the institution, and your not being able to pass this exam. Have you considered getting accommodations?"
And he was, like, "Wow, my psychiatrist said the same thing." He ends up taking the test orally, and now he’s a licensed engineer with his PhD. That becomes an issue of it’s not that you don’t have the knowledge, but it’s the issue of how the test is given and how you demonstrate your knowledge that has become a problem.
So, I tell families and institutions and persons being treated that it's a different way of learning, and that's okay. Oddly enough, a lot of people with ADHD are good athletes, are great artists. Many of them are doctors. Now, realizing that with ADHD, they tend to hyperfocus on things they love to do. So if it gives them a lot of enjoyment, they tend to hyperfocus on those things. So, if you're a doctor and you want to be a psychiatrist or a cardiologist or an anesthesiologist or whatever, and school and grades is your thing, then you hyperfocus on those things.
But the thing is that even though you're an X kind of doctor and you're making half a million dollars a year, you can't ever remember to pay your car note or your house note, or you always get busy at work and forget to pick up the kids from daycare, or you wait till the last minute, traffic is hit, and now your wife is calling, it's 6:35 and you're supposed to pick up the kids by 6:30.
So all of those things go into the overall effect, and so I try to let people know it's a different way of learning, a different way of thinking, and we can do something to help that.
Dr. Max Wiznitzer: So what you're saying is we want to make sure people are proactive and not reactive.
Dr. Napoleon Higgins: I would always say definitely so. The issue of being proactive and taking care of these things early is the best intervention that you can make.
Dr. Max Wiznitzer: Well, how would you summarize our whole discussion when we're talking about the issue of the recognition and the intervention for ADHD in the African American and other underserved communities? If you were basically to say it just in a few sentences, what would be the message that you would send out to everybody?
Dr. Napoleon Higgins: I would say the message would be we must educate individuals. We must take our time to be embedded in the communities, and we also need to make sure that we're listening to what the community is wanting us to do. And if we can listen to them, educate at the same time, and come to an intervention of understanding with compassion and love, I think the job can get done.
Dr. Max Wiznitzer: Thank you, Dr. Higgins. Thank you very much for your time.
Dr. Napoleon Higgins: Thank you.
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