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30 Jul 2020

Dong Q et al. Curr Psychiatry Rep 2020; 22: 27

A growing body of research has highlighted the importance of sociocultural factors in the recognition, diagnosis and treatment of ADHD. Emerging findings are promising on cultural adaptations of evidence-based interventions for ADHD within a multi-tiered system of support (MTSS), which integrates classroom instruction, evidence-based interventions and ongoing assessments to meet the needs of all students, including those with ADHD.

In the US, as a means to improve the identification and treatment of culturally diverse children and young people with ADHD and their families, a primer has been prepared to guide mental health professionals on the implementation of culturally responsive practices within an MTSS framework when collaborating with schools.

Tier 1 – screening and culturally responsive school-wide approaches

Across a school, teachers establish rules and provide consequences to promote on-task behaviour and minimise disruptive behaviours. These are applied at all tiers and for all students, but they may need to be intensified for students suspected to have ADHD, and differentiated for students from culturally and linguistically diverse backgrounds. Classroom behavioural interventions such as the “Good Behaviour Game*” have been shown to increase desirable behaviour in children with ADHD, and are also effective for children from culturally, linguistically and socioeconomically diverse backgrounds. To enhance effectiveness in this group, mental health professionals can encourage teachers to use cultural adaptations with diverse children.

Classroom management programmes such as “Incredible Years” focus on promoting prosocial behaviour, emotional regulation, impulse control and social problem-solving, and can be implemented with the entire class or with a smaller group of children. Students learn from various social problem-solving scenarios and vignettes, which should be adapted to the students’ cultural backgrounds after consultation and input from caregivers.

Universal screening of academic work and behaviour is also a component of Tier 1, as it identifies subgroups of students, including those with suspected ADHD, who may not respond well to general classroom-level strategies. In addition to screening, psychiatrists and psychologists can collaborate with schools to develop and implement school-wide workshops on mental health awareness (caregiver psychoeducation), in order to increase caregiver engagement while promoting positive behaviour.

Tier 2 – culturally relevant targeted interventions

Children who demonstrate persistent learning and behavioural difficulties at Tier 1 are likely to require Tier 2 targeted intervention. Generally, Tier 2 interventions supplement general classroom instruction and provide students with additional support that increases in intensity or duration and can often be provided to a small group of students. This may include organisational skills training, token economies and social skills training. One intervention that is commonly used is the daily report card, which involves monitoring 3–5 targeted behaviours in the classroom on a daily basis. When the child reaches the daily or weekly goal, they receive a reward from the caregivers or extended family members at home. Cultural adaptations include identifying caregiver concerns about the use of praise or positive attention that may, for example, be inconsistent with an authoritarian parenting style.

School-based problem-solving teams must also take the time to observe, define and analyse the child’s problematic behaviours by conducting a functional behavioural assessment. Essential to this process is understanding the cultural context of the behaviour and implementing these considerations when developing behaviour plans. Psychiatrists and psychologists can play an important role in consulting with school-based problem-solving teams when conducting culturally responsive functional behavioural assessments.

Tier 3 – individualised assessment and cultural adaptation of interventions

Persistent behaviours after receiving Tier 2 support may require more intensive interventions and further assessment for ADHD. Due to potential stigma, a diagnosis of ADHD may not be desired by some caregivers. However, it may be required to justify forms of support and treatment, thus discussions with caregivers about the different options provided in school and primary care settings may become warranted. Specifically, psychiatrists or psychologists should consult with school-based problem-solving teams to ensure communication with caregivers while considering cultural and linguistic diversity. Specifically, explanations about social and biological causes of persistent behaviour problems should be presented in jargon-free and understandable terms, along with discussion about core beliefs and social stigma within the family or school. If caregivers are in agreement with further assessment to determine ADHD, the evaluation should consider data gathered from multiple informants (e.g. teachers, caregivers and the child/adolescent).

If a diagnosis of ADHD is determined, necessary following steps may include a behavioural consultation, caregiver or parent training, pharmacological treatment and associated monitoring of progress. In all these aspects, different cultures and parenting styles should be respected and taken into account during planning and process. For example, although progress monitoring is key to determining how well students with ADHD are responding to services, it is important for mental health and medical professionals to encourage school personnel to use measures that are valid within culturally and linguistically diverse populations.

In conclusion, this report describes a comprehensive tiered approach to managing ADHD in children and adolescents, including initial behavioural screening and prevention, evidence-based interventions tailored to development and family culture, and collaboration between mental health professionals, schools and families in the evaluation of outcomes for children with ADHD. Engaging in these approaches can promote culturally responsive practices and may improve the quality of services provided to children with ADHD.

Read more about culturally responsive approaches for addressing ADHD here


*In the Good Behaviour Game, the classroom is divided into two teams where a team receives a mark on the board when the teacher observes an inappropriate behaviour (e.g. talking out of turn and out-of-seat behaviour). The team with the fewest rule violations receives a group reward, or if neither team received more than five rule violation marks (or another set criterion), the entire classroom receives a reward

Dong Q, Garcia B, Pham AV, et al. Culturally responsive approaches for addressing ADHD within multi-tiered systems of support. Curr Psychiatry Rep 2020; 22: 27.

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