Challenges in ADHD Care for Children of Color – Part 2
Podcast Date: January 29, 2020
- Learn about the barriers to treatment for children of color with ADHD.
- Learn how professionals can develop cultural awareness.
- Gain skills on how to change the conversation about mental health and people of color.
- Learn how parents of color can advocate for their child.
- Identify how treatment can be provided equitably throughout different communities.
Melvin Bogard: You're listening to the All Things ADHD podcast. Hello, I'm your host, Melvin Bogard. My guest today is Dr. Roberto Olivardia. Welcome.
Roberto Olivardia: Thank you for having me.
Melvin Bogard: So please tell me more about yourself.
Roberto Olivardia: Sure. I am a clinical psychologist, and a lecturer in the department of psychiatry at Harvard Medical School in Boston, Massachusetts. I specialize in the treatment of ADHD, as well as working with eating disorders, obsessive-compulsive disorder, body dysmorphic disorder. I see patients of all ages, and specifically with ADHD, I see a lot of people with ADHD and comorbid disorders, like ADHD and binge eating disorder, or bipolar disorder, substance abuse. I’m really happy to be here on this podcast.
Melvin Bogard: We are happy to have you. This is part two of Challenges in ADHD Care for Children of Color. In this episode, we are talking about how educators and healthcare providers can be more transcultural, how African-American parents can advocate for their child, how to get the Black community to talk more about mental health issues, and so much more. Dr. Olivardia, how do we help educators to be more transcultural in their thinking and in the classroom?
Roberto Olivardia: We definitely have to do a lot more training with educators; also in understanding how school systems deal and work with ADHD or kids with learning disabilities. Studies find that African-American children, for example, who are diagnosed with ADHD are more likely to be put in a special ed classroom, when they may not need those services of special education. Some do, but ADHD in and of itself doesn't have to warrant necessarily a different classroom. It might warrant accommodations within a classroom. Unlike, let's say, having dyslexia, you may need a different classroom, a different level of instruction. To just group the kids with ADHD with kids that might be on the autism spectrum, or might have dyslexia, or might have other issues, they're not getting what they need in that way.
We want to look at it from the institutional perspective of, okay, so what is your—and this is talking to the school—your process of identifying ADHD? So, when a teacher notices, because teachers are in an amazing role of really... they're often the first people that sometimes parents hear that say, "You know, I'm noticing something in your child." Now, a teacher can't diagnose, but they can say it warrants some further exploration or examination. Again, keeping in mind that certain school systems that might have very poor resources, or where the threshold of behavior, it might be difficult for the child who has ADHD but behaves very well, who's under the radar, might be much harder to detect, because there are a lot of children that might be acting out in more externalizing ways.
Again, for parents, it's easy when a child is acting out to notice them. It's harder [to recognize] girls with ADHD, which is why African-American girls with ADHD are the least identified often in these cohorts, because girls with ADHD often are more internalized with their behavior. They're more kind of quiet, their self-esteem is low, more depressed; they don't act it out in the same way.
Educating teachers about, one, what ADHD is in general. Because I find a lot of times we still have a way to go in terms of educating about ADHD, that intersection between a diagnosis and communities of color and understanding how that might land on families, and understanding their view and philosophy, and speaking to that. And speaking to what the benefits of treatment, the benefits of diagnosis are. This is not an indictment on your parenting, that this is not a weakness at all in that way.
I think that's where the messaging gets lost. I've heard from people of color who have said, just in general about depression or other issues, "We don't really talk about those in our circles. We think those are white people problems," in that way. There is a stigma that's much bigger than I think even with ADHD we assume is less so. But again, what we're finding is that that's less so in Caucasian cohorts, not so much in communities of color. Also understanding that ADHD is heritable, and so, a lot of these kids with ADHD have parents with ADHD that may or may not have been managed in some ways. When you're working with any parent, to understand that you could be unearthing their own past traumas of being in school and being labeled bad, and thinking, "Oh, I don't want that for my child."
A lot of the "defensiveness, suspiciousness, distrust"—these terms that unfortunately have this pejorative sense that we sort of put on the parent—as opposed to saying, "Well, wait a minute. Maybe there's a reason that these parents feel this way. Maybe it's warranted, not only individually but just culturally and historically why that is." That's where we need to train educators and individuals. Because teachers really are amazing individuals. They have such a hard job. It's not pointing fingers or blaming them. It's more, again, understanding that all of us carry our own implicit biases in that way.
Melvin Bogard: Many Black people struggle to talk about mental health issues. How do we start the conversation?
Roberto Olivardia: I think it's really reaching people where they are at. For example, I worked with someone who found that talking in their church about mental health and bringing that into the church community. Whether it's the boys’ and girls’ clubs, after school programs. It certainly helps when there's visibility of successful African-American individuals who have ADHD in that way. Podcasts like this, talks at ADHD conferences that are geared towards people of color and bringing them together.
I remember at a CHADD conference some years back—they have these sort of networking groups, typically in the evenings—I had facilitated one on people of color, and there were a lot of moms and dads, African American, Hispanic, who were in the room. It was the first time that many of them had even met a fellow parent of color to talk about this. Just to even reach out and have somebody else reach out and speak of that experience, and those special concerns, is powerful. I mean, that's really, really powerful.
Melvin Bogard: Parents need to be more proactive as well, but what role do they play in the success of their child and advocating for fairness?
Roberto Olivardia: Absolutely. I think with parents, a lot of it is them understanding, again, getting the education, understanding that it's okay to ask for help. That it doesn't mean that they have failed, that they are weak, or that they are bad parents in any way. And also, one of the other concerns I hear from parents is they fear, again, this idea of how will this follow them. If my child wants to go in the military, in a future job that they have, is this something that's going to sort of follow them that will cut off their opportunities. And again, emphasizing the importance of how proper treatment is going to be better for them.
With that, it's also if they have issues, let's say if they get their child diagnosed, and let's say medication or counseling. The upsides to what happened over the past year is, with all the tragedy that happened with COVID, but one thing is that therapy services have gone remote and virtual, and studies show that they can be just as effective. Now, that has really opened up something very exciting for a lot of communities of color, and particularly for people of lower socioeconomic groups, [for whom it] has been difficult to find transportation, to find the time to get to a counselor. That can open up services. You want to do everything you can, and to know that the problem is not you, the problem is that there are these barriers that really shouldn't be there. Unfortunately, it often takes the minority to inform the majority that those barriers exist. And how do we all then work together in that way?
Engage with your child, and let your child know that they're not defective, their brain is not wrong. I think a lot of times, parents are hesitant because they don't want their child to feel different. And I tell them, well, they are different and they feel different. Different doesn't have to be bad. Different doesn't have to be defective. Like, okay, "I don't want my child to have that label," it often helps them to understand, "Oh, okay. There's something that explains this. It's not that I'm dumb. It's not that I'm weak." Those are the terms that they're going to think of for themselves unless they get a frame that helps them understand what the issue is.
Melvin Bogard: What would a more culturally sensitive diagnostic tool look like?
Roberto Olivardia: That's a great question. This is where, even when we take it from the assessment level, of really reexamining all of our diagnostic tools in terms of, is this culturally competent in terms of the questions that we're asking and how we're understanding. This can lead again to both underdiagnosis and overdiagnosis, because if you say, "Are there times of the day that you're distracted and inattentive?" Well, we also know that that could be due to anxiety. That could be due to if you're growing up in an abusive family. That could be because you're hungry. That could be because you didn't sleep well because there's no heat in your house. There are lots of things. I would say at the very basic level, we never want to just look at a piece of paper, a survey, a test, and say, "Okay, this person has or doesn't have it." It's taking that and really connecting to the story of that individual.
One of the things that communities of color often value is the sort of art of the narrative, the art of storytelling, and really understanding somebody in a specific context. As clinicians, as people who assess, it's to just have somebody talk and say, "Tell me what your concerns are, and share with me," if it's a parent talking about their child, "who your child is. What are your concerns?" And to let them know that boxes that get checked are supplemental. We don't want that to determine. At the end of the day, if a child is not succeeding in school, then there's something happening. Even if the test scores show X, Y and Z, we're not getting to the heart of the matter. We want to look at all of the issues that are involved, I think that at the very basic level, from a research perspective, is that we need more research that specifically focuses on people of color and validating these instruments. We might find that some of these instruments that we use are culturally competent, but we don't 100% know until we've normed it and have reference groups that are primarily people of color. There are individuals of color, and then there's also different socioeconomic groups, whether they're people of color or not. That's a whole other variable of intersectionality that's really important.
Having said that, studies still show that even sort of higher socioeconomic African-American groups still struggle with proper assessment, proper diagnosis, proper treatment. A lot of the stigma. Of course, they're still subject to racism, discrimination. It's still there, regardless of what socioeconomic group. If you are of a lower socioeconomic group and a person of color, there's a lot there that, we have to understand that in those cases, one plus one doesn't equal two. One plus one equals five, meaning that there's an exponential effect when you have these variables. That’s why we see African-American girls who are growing up in lower socioeconomic, there's a tremendous amount of barrier in terms of proper identification for that.
Melvin Bogard: How do we get more healthcare professionals invested in treating all people fairly?
Roberto Olivardia: I think it's really with education, and I think it starts very early. I have to say, I feel very, very fortunate. I got my PhD at the University of Massachusetts in Boston, and this program was way ahead of its time, where it's very focused on cross-cultural psychology, cultural competence—when I was in graduate school—every course we had from assessment to psychopathology. We also had our own cultural mental health course. But embedded in every course we looked at, okay, so this is how we learn about it; however, let's look at the research. We'd find that this was normed with white men, and what does this mean for women? What does this mean for LGBTQ? What does this mean for African Americans? We need more of that model in graduate school programs for psychologists, social work programs, medical schools.
I have to say, I am seeing more of that in terms of diversity training and understanding, again, that when you have a patient who comes through the door, understanding their story and understanding the context of those symptoms. So, for example, and this was just a casual conversation I had with a physician at a conference a couple years ago who said, "Yeah, sometimes I see patients, and by the time they come to see me their diabetes is so out of control. Come on, you need to come from when this problem is starting." As if again, this sort of implicit blame, or explicit blame, on the patient. Like, "Oh, you came way too late."
Let's understand what might've gotten in the way. Maybe that person has copays that they can't afford. Maybe they're working two, three jobs and they don't have time. Maybe they're raising their children and they're like, "You know what, if I have to pay for medical services, it'll be for my children, not for me." Maybe they can't afford healthy food. And so, unfortunately, the food that they can afford is going to be food that's high in fat and that isn't going to be good for their health. All of that. So, as opposed to understanding, "Okay, so tell me that, and now I can understand that."
Even though this doctor was a good person who wanted to treat their patient, but if we understand if there's any sense of judgment—even implicitly—that comes through, like, "Whoa, you waited way too long for this," without understanding the context, that patient feels shamed. They feel distrustful. They feel, "Well, how do I expect to put myself in this person's care?" Those kinds of conversations.
Again, there's blatant full-out racism. More so, we see these kinds of implicit biases and a lack of really understanding the full context. That's where we in the medical, mental health professional world need to continue to step up and train as we're training individuals to do that. And then having continuing education around that.
I'm in Massachusetts, and in Massachusetts, every two years we have to renew our license as psychologists. It was mandatory that we had this cultural course in terms of looking for continuing ed, as well as other courses. And I think that has to be a requirement, making it important for people to look at. Even people who are very politically aware, very socially aware who are like, "Oh yeah, no. I understand that." It's like, no, you understand about, certainly, racism. You may not be racist, absolutely. However, do you understand fully?” And so that's what we have to do in terms of educating people.
Melvin Bogard: Any final words?
Roberto Olivardia: I would implore anyone who listens to the podcast, Google African American and ADHD, people of color, just find resources online. Read articles, hear the voices of people who have experienced it and have experienced some of the barriers.
Melvin Bogard: Great suggestions. Thank you.
Roberto Olivardia: My pleasure. Thank you for doing this topic and having many people in the ADHD community talking about it.
Melvin Bogard: Thank you for listening to another episode of All Things ADHD. To learn more about ADHD, visit CHADD at CHADD.org.
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