Culturally Appropriate Assessment of Functioning in Diverse Children: Development and Preliminary Validation of the FX-II Scale in Mexico.

OBJECTIVE: We sought to develop and provide preliminary validation for a questionnaire evaluating functioning related to ADHD (i.e., the FX-II) with a particularly underserved group (i.e., Mexican youth). METHOD: 191 Mexican raters completed the FX-II alongside measures of ADHD symptoms, impairment, cultural values, and demographics: 127 raters were caregivers of treatment-naïve youth (i.e., community sample); 32 raters were caregivers and 32 raters were teachers of youth participating in a school-based program for attention/behavior concerns (i.e., clinical sample). RESULTS: We created the 52-item FX-II Scale by adapting a culturally appropriate and psychometrically sound measure of impairment (i.e., the ADHD-FX) to assess functioning most relevant to Spanish-speaking families of children with ADHD (i.e., academic, social/emotional, and familial functioning). The FX-II demonstrated strong reliability, convergent and divergent construct validity, and predictive validity. CONCLUSION: The FX-II appears to be a beneficial tool for evaluating functioning related to ADHD in Mexican children and future validation efforts in broader populations are warranted.

Validity of Sluggish Cognitive Tempo in South America: An Initial Examination Using Mother and Teacher Ratings of Chilean Children.

OBJECTIVE: To examine the validity of sluggish cognitive tempo (SCT) and ADHD-inattention (ADHD-IN) symptoms in children from Chile. METHOD: Mothers and teachers rated SCT, ADHD-IN, ADHD-hyperactivity/impulsivity (ADHD-HI), oppositional defiant disorder (ODD), anxiety, depression, academic impairment, social impairment, and peer rejection (teachers only) in 652 Chilean children (55% boys) aged 6 to 14 years. RESULTS: For both mother and teacher ratings, the eight SCT symptoms and nine ADHD-IN symptoms showed substantial loadings on their respective factors (convergent validity) along with loadings close to zero on the alternative factor (discriminant validity). ADHD-IN showed a uniquely stronger relationship than SCT with ADHD-HI and ODD whereas SCT showed a uniquely stronger relationship than ADHD-IN with anxiety and depression. Although ADHD-IN uniquely predicted academic impairment and social difficulties, SCT did not. CONCLUSION: This study provides the first evidence for the validity of SCT among children outside of North America or Western Europe.

Differences in ADHD medication usage patterns in children and adolescents from different cultural backgrounds in the Netherlands.

PURPOSE: Differences in incidence and prevalence of ADHD medication use between ethnic groups have been reported. Goal of this study was to determine whether there are also differences in usage patterns of ADHD medication among native Dutch children and adolescents and those with a Moroccan, Turkish and Surinam cultural background in the Netherlands between 1999 and 2010. METHODS: In a cohort of ADHD patients <19 years (N = 817) incident use and discontinuation of ADHD medication were measured for ethnicity and adjusted for age, gender and socio-economic status. RESULTS: A significant higher proportion of ADHD-diagnosed patients from Moroccan (32 %) and Turkish (42 %) cultural background never used ADHD medication compared to Dutch natives (21 %). One-fifth of native Dutch and Turkish patients already used ADHD medication before the ADHD diagnosis date. Discontinuation of ADHD medication within 5 years was significantly higher in Moroccan [HR 2.4 (95 % CI 1.8-3.1)] and Turkish [HR 1.7 (95 % CI 1.1-2.6)] patients. A sensitivity analysis with a zip code-matched comparison between Dutch natives and non-natives showed similar results, suggesting this effect is probably not explained by socio-economic status (SES). CONCLUSION: Differences are found in prescribing and use of ADHD medication between patients with a different cultural background. Native Dutch and Turkish patients start more frequently with ADHD medication before the ADHD diagnose date, which can be an indication of differences in either referral patterns and/or access to care. A higher percentage of patients with a Moroccan and Turkish cultural background never start using ADHD medication at all and discontinuation rate is higher compared to Dutch natives and Surinamese.

Imputing Missing Race/Ethnicity in Pediatric Electronic Health Records: Reducing Bias with Use of U.S. Census Location and Surname Data.

OBJECTIVE: To assess the utility of imputing race/ethnicity using U.S. Census race/ethnicity, residential address, and surname information compared to standard missing data methods in a pediatric cohort. DATA SOURCES/STUDY SETTING: Electronic health record data from 30 pediatric practices with known race/ethnicity. STUDY DESIGN: In a simulation experiment, we constructed dichotomous and continuous outcomes with pre-specified associations with known race/ethnicity. Bias was introduced by nonrandomly setting race/ethnicity to missing. We compared typical methods for handling missing race/ethnicity (multiple imputation alone with clinical factors, complete case analysis, indicator variables) to multiple imputation incorporating surname and address information. PRINCIPAL FINDINGS: Imputation using U.S. Census information reduced bias for both continuous and dichotomous outcomes. CONCLUSIONS: The new method reduces bias when race/ethnicity is partially, nonrandomly missing.

Childhood ADHD symptoms are associated with lifetime and current illicit substance-use disorders and in-site health risk behaviors in a representative sample of Latino prison inmates.

OBJECTIVE: This study aimed to explore retrospective childhood ADHD symptomatology, psychiatric comorbidity, rates of substance-use disorders (SUD), as well as their association with high-risk health behaviors in prison and adverse health outcomes. METHOD: A randomly selected representative sample of inmates in the Puerto Rico correctional system (N = 1,179) was assessed with the Spanish-language Wender Utah Rating Scale (WURS); the Composite International Diagnostic Interview (CIDI) modules for lifetime/current major depression disorder (MDD), generalized anxiety disorder (GAD), and SUD; the Davidson Trauma Scale (DTS; posttraumatic stress disorder [PTSD]); and self-reports of in-site high-risk behaviors. RESULTS: Wald χ(2) tests revealed significant associations of ADHD with MDD and PTSD, as well as increased risk for overdosing and intravenous drug use in prison. A logistic regression model adjusted for mood and anxiety comorbidity predicted lifetime SUD diagnosis (odds ratio = 2.38; 95% confidence interval = [1.15, 4.94]). CONCLUSION: Our results provide further evidence on the association of drug dependence and ADHD symptoms, and their overrepresentation among prison inmates.

Trastorno por déficit de atención e hiperactividad en niños aymara: primera aproximación clínica / Attention deficit hyperactivity disorder in Aymara children

Background: The assessment of Attentional Deficit Hyperactivity Disorder (ADHD) among ethnic groups may reveal environmental or cultural variables that influence the appearance of this disorder. Aim: To assess the presence and characteristics of ADHD in two communities of the inland Arica valleys (Azapa and Lluta), where the Aymara population predominates. Material and Methods: Startingfrom a screening based on the Conner's test, we evaluated 79 children aged 8 to 13 years. Sixty children were of Aymara origin and 19 children were of non-Aymara origin. Twenty Aymara and 9 non-Aymara children had ADHD. They were compared with a group of patients from Santiago, Chile (110 children) that were previously assessed. Results: Patientsfrom Azapa/Lluta displayed similar characteristics to those from Santiago. However the former had significantly less psychiatric comorbidities than the latter. On the other hand, the non-Aymara subgroup of Azapa/ Lluta displayed an increased rate of comorbidities and was exclusively of the combined subtype, although their sample size is too small to draw strong conclusions. Conclusions: Although we cannot dismiss biological variables, the importance of family values and the respect to authorities may be protective factors for ADHD, associated to Aymara culture. Our findings suggest that the clinical characteristics of ADHD are not uniform among ethnic groups and cultures. The relative contribution of environmental and genetic factors in this variability remain to be determined.

Prenatal polycyclic aromatic hydrocarbon (PAH) exposure and child behavior at age 6-7 years.

BACKGROUND: Airborne polycyclic aromatic hydrocarbons (PAH) are widespread urban air pollutants from fossil fuel burning and other combustion sources. We previously reported that a broad spectrum of combustion-related DNA adducts in cord blood was associated with attention problems at 6-7 years of age in the Columbia Center for Children's Environmental Health (CCCEH) longitudinal cohort study. OBJECTIVES: We evaluated the relationship between behavioral problems and two different measures of prenatal exposure--both specific to PAH--in the same cohort. METHODS: Children of nonsmoking African-American and Dominican women in New York City (NYC) were followed from in utero to 6-7 years. Prenatal PAH exposure was estimated by personal air monitoring of the mothers during pregnancy as well as by the measurement of DNA adducts specific to benzo[a]pyrene (BaP), a representative PAH, in maternal and cord blood. At 6-7 years of age, child behavior was assessed using the Child Behavior Checklist (CBCL) (n = 253). Generalized linear models were used to test the association between prenatal PAH exposure and behavioral outcomes. RESULTS: In multivariate analyses, high prenatal PAH exposure, whether characterized by personal air monitoring (greater than the median of 2.27 ng/m³) or maternal and cord adducts (detectable or higher), was positively associated with symptoms of Anxious/Depressed and Attention Problems (p ≤ 0.05). CONCLUSION: These results provide additional evidence that environmental levels of PAH encountered in NYC air can adversely affect child behavior.

Validity of the sluggish cognitive tempo, inattention, and hyperactivity symptom dimensions: neuropsychological and psychosocial correlates.

This study examined the latent structure and validity of inattention, hyperactivity-impulsivity, and sluggish cognitive tempo (SCT) symptomatology. We evaluated mother and teacher ratings of ADHD and SCT symptoms in 140 Puerto Rican children (55.7% males), ages 6 to 11 years, via factor and regression analyses. A three-factor model (inattention, hyperactivity-impulsivity, and SCT) provided the best fit for both sets of ratings. Inattention was the strongest correlate of lower scores on neuropsychological, achievement, and psychosocial measures. Externalizing problems were most strongly associated with hyperactivity-impulsivity, and internalizing problems were most strongly associated with parent-rated SCT and teacher-rated Inattention. SCT was not associated with executive function but was negatively associated with math. Inattention accounted for a disproportionate amount of ADHD-related impairment, which may explain the restricted discriminant validity of DSM-IV types. The distinct factors of hyperactivity-impulsivity and SCT had unique associations with impairing comorbidities and are roughly equivalent in predicting external correlates of ADHD-related impairment.

[Attention deficit hyperactivity disorder in Aymara children]. / Trastorno por déficit de atención e hiperactividad en niños aymara: primera aproximación clínica.

BACKGROUND: The assessment of Attentional Deficit Hyperactivity Disorder (ADHD) among ethnic groups may reveal environmental or cultural variables that influence the appearance of this disorder. AIM: To assess the presence and characteristics of ADHD in two communities of the inland Arica valleys (Azapa and Lluta), where the Aymara population predominates. MATERIAL AND METHODS: Starting from a screening based on the Conner's test, we evaluated 79 children aged 8 to 13 years. Sixty children were of Aymara origin and 19 children were of non-Aymara origin. Twenty Aymara and 9 non-Aymara children had ADHD. They were compared with a group of patients from Santiago, Chile (110 children) that were previously assessed. RESULTS: Patients from Azapa/Lluta displayed similar characteristics to those from Santiago. However the former had significantly less psychiatric comorbidities than the latter. On the other hand, the non-Aymara subgroup of Azapa/Lluta displayed an increased rate of comorbidities and was exclusively of the combined subtype, although their sample size is too small to draw strong conclusions. CONCLUSIONS: Although we cannot dismiss biological variables, the importance of family values and the respect to authorities may be protective factors for ADHD, associated to Aymara culture. Our findings suggest that the clinical characteristics of ADHD are not uniform among ethnic groups and cultures. The relative contribution of environmental and genetic factors in this variability remain to be determined.

[Risk of attention deficit/hyperactivity disorder in Aymara and Rapa-Nui school children: association with dopaminergic system polymorphisms]. / Riesgo de déficit atencional/hiperactividad en escolares Aymara, Rapa-Nui y de Santiago de Chile: Posible contribución de polimorfismos genéticos del sistema dopaminérgico.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) is a common, highly heritable neurobiological disorder of childhood onset, characterized by hyperactivity, impulsiveness or inattentiveness. AIM: To search for differences in risk for ADHD and its components among Chilean native and mixed populations and to look forpossible associations with dopamine receptor D4 (DRD4) and dopamine transporter 1 (DAT1) polymorphisms. MATERIAL AND METHODS: School teachers were requested to complete the Conners test, which uses DSM-IV criteria, to screen for ADHD risk among Aymara and Rapa-Nui students. RESULTS: Rapa-Nui children from Easter Island had the highest risk of hyperactivity/impulsiveness. Aymara children from the Arica-Parinacota Region had lower scores. Although inattentiveness scores had lower differences between groups, overall ADHD score differences among studied populations were highly significant. DRD4 and DAT1 alleles had a heterogeneous distribution. Easter islanders had more divergent frequencies, mostprobably as a result of separate migration routes utilized at different timeperiods during the colonization of America and Polynesia. CONCLUSIONS: The comparison of ADHD risk parameters between Rapa-Nui and Aymara children showed marked differences. Allele distri-bution of dopamine polymorphisms in Easter Island was also significantly different from northern Chile, due probably to different colonization histories. These findings suggest that higher ADHD risk scores in Easter Island children may be linked to the presence of different DRD4 alleles.

Short-term persistence of DSM-IV ADHD diagnoses: influence of context, age, and gender.

OBJECTIVE: Little is known about the effect of social context and gender on persistence of attention-deficit/hyperactivity disorder (ADHD) in children of early and middle school years. The study compared persistence of DSM-IV ADHD and ADHD not otherwise specified (NOS) over 2 years in two groups of Puerto Rican children. METHOD: A three-wave study obtained data on Puerto Rican children 5 through 13 years of age at baseline. Samples were drawn in the South Bronx in New York (n = 1,138) and two metropolitan areas in Puerto Rico (n = 1,353). The Diagnostic Interview Schedule for Children Version IV was used to diagnose ADHD and ADHD-NOS. RESULTS: ADHD or ADHD-NOS diagnosis at wave 1 strongly predicted disorder at waves 2 and 3. ADHD had a significantly stronger predictive effect than ADHD-NOS consistently across site and gender. There was a significant interaction with baseline age. For those younger at baseline, the strength of the prediction of ADHD-NOS was relatively weak; for older children, the presence of ADHD-NOS at baseline predicted risk of subsequent ADHD or ADHD-NOS. CONCLUSIONS: Persistence of ADHD in children of similar ethnicity does not manifest differently across context and gender. Results suggest that age-specific symptom criteria and modification of age-of-onset criteria should be considered for the diagnosis.

Riesgo de déficit atencional/hiperactividad en escolares Aymara, Rapa-Nui y de Santiago de Chile: Posible contribución de polimorfismos genéticos del sistema dopaminérgico / Risk of attention deficit/hyperactivity disorder in Aymara and Rapa-Nui school children: Association with dopaminergic system polymorphisms

Background: Attention deficit/hyperactivity disorder (ADHD) is a common, highly heritable neurobiological disorder of childhood onset, characterized by hyperactivity, impulsiveness or inattentiveness. Aim: To search for differences in risk for ADHD and its components among Chilean native and mixed populations and to look forpossible associations with dopamine receptor D4 (DRD4) and dopamine transporter 1 (DAT1) polymorphisms. Material and Methods: School teachers were requested to complete the Conners test, which uses DSM-IV criteria, to screen for ADHD risk among Aymara and Rapa-Nui students. Results: Rapa-Nui children from Easter Island had the highest risk of hyperactivity/impulsiveness. Aymara children from the Arica-Parinacota Region had lower scores. Although inattentiveness scores had lower differences between groups, overall ADHD score differences among studied populations were highly significant. DRD4 and DAT1 alleles had a heterogeneous distribution. Easter islanders had more divergent frequencies, mostprobably as a result of separate migration routes utilized at different timeperiods during the colonization of America and Polynesia. Conclusions: The comparison of ADHD risk parameters between Rapa-Nui and Aymara children showed marked differences. Allele distri-bution of dopamine polymorphisms in Easter Island was also significantly different from northern Chile, due probably to different colonization histories. These findings suggest that higher ADHD risk scores in Easter Island children may be linked to the presence of different DRD4 alleles.

Distinguishing features of cuban children referred for professional help because of ADHD: looking beyond the symptoms.

OBJECTIVE: To distinguish Cuban children clinically referred because of ADHD from an at-risk community sample and a community control group in terms of symptoms, associated difficulties and impairment of family and peer relations. METHOD: Parents and teachers of 1,036 children (6-8 years old) completed an established ADHD rating scale and a behavioral screening measure, including peer functioning.We also administered a structured clinical interview and measures of family impairment to the clinical sample and to an at-risk community-based subsample. RESULTS: Although both clinical and at-risk groups displayed more externalizing and internalizing symptoms than controls, referred children were not only characterized by higher levels of ADHD symptoms, but also by greater impairment of family and peer relations than at-risk community children or community controls. CONCLUSION: The findings suggest that ADHD has major consequences on the family and peer functioning of Cuban children, which may lead to their referral for treatment.

Organophosphate pesticide exposure and attention in young Mexican-American children: the CHAMACOS study.

BACKGROUND: Exposure to organophosphate (OP) pesticides, well-known neurotoxicants, has been associated with neurobehavioral deficits in children. OBJECTIVES: We investigated whether OP exposure, as measured by urinary dialkyl phosphate (DAP) metabolites in pregnant women and their children, was associated with attention-related outcomes among Mexican-American children living in an agricultural region of California. METHODS: Children were assessed at ages 3.5 years (n = 331) and 5 years (n = 323). Mothers completed the Child Behavior Checklist (CBCL). We administered the NEPSY-II visual attention subtest to children at 3.5 years and Conners' Kiddie Continuous Performance Test (K-CPT) at 5 years. The K-CPT yielded a standardized attention deficit/hyperactivity disorder (ADHD) Confidence Index score. Psychometricians scored behavior of the 5-year-olds during testing using the Hillside Behavior Rating Scale. RESULTS: Prenatal DAPs (nanomoles per liter) were nonsignificantly associated with maternal report of attention problems and ADHD at age 3.5 years but were significantly related at age 5 years [CBCL attention problems: ß = 0.7 points; 95% confidence interval (CI), 0.2-1.2; ADHD: ß = 1.3; 95% CI, 0.4-2.1]. Prenatal DAPs were associated with scores on the K-CPT ADHD Confidence Index > 70th percentile [odds ratio (OR) = 5.1; 95% CI, 1.7-15.7] and with a composite ADHD indicator of the various measures (OR = 3.5; 95% CI, 1.1-10.7). Some outcomes exhibited evidence of effect modification by sex, with associations found only among boys. There was also limited evidence of associations between child DAPs and attention. CONCLUSIONS: In utero DAPs and, to a lesser extent, postnatal DAPs were associated adversely with attention as assessed by maternal report, psychometrician observation, and direct assessment. These associations were somewhat stronger at 5 years than at 3.5 years and were stronger in boys.

Culturally adapted cognitive-behavior therapy: integrating sexual, spiritual, and family identities in an evidence-based treatment of a depressed Latino adolescent.

The article described and illustrated how a culturally adapted cognitive-behavioral therapy (CBT) can maintain fidelity to a treatment protocol while allowing for considerable flexibility to address a patient's values, preferences, and context. A manual-based CBT was used with a gay Latino adolescent regarding his sexual identity, family values, and spiritual ideas. The adolescent suffered from a major depression disorder and identified himself as gay and Christian within a conservative and machista Puerto Rican family. CBT promoted personal acceptance and active questioning of homophobic thoughts in a climate of family respect. CBT enabled identity formation and integration, central to the development of a sexual identity for lesbian, gay, bisexual, and transgender youth, with remission of the patient's depression and better family outcomes.

Parent-child interaction therapy for Puerto Rican preschool children with ADHD and behavior problems: a pilot efficacy study.

This study evaluates the initial efficacy of the Parent-Child Interaction Therapy (PCIT) for Puerto Rican preschool children aged 4-6 years with a diagnosis of attention-deficit/hyperactivity disorder (ADHD), combined or predominantly hyperactive type, and significant behavior problems. Thirty-two families were randomly assigned to PCIT (n = 20) or a 3.5-month waiting-list condition (WL; n = 12). Participants from both groups completed pretreatment and posttreatment assessments. Outcome measures included child's ADHD symptoms and behavior problems, parent or family functioning, and parents' satisfaction with treatment. ANCOVAs with pretreatment measures entered as covariates were significant for all posttreatment outcomes, except mother's depression, and in the expected direction (p < .01). Mothers reported a highly significant reduction in pretreatment hyperactivity and inattention and less aggressive and oppositional-defiant behaviors, conduct problems assessed as problematic, parenting stress associated with their child's behavior, and an increase in the use of adequate parenting practices. For the WL group, there were no clinically significant changes in any measure. Treatment gains obtained after treatment were maintained at a 3.5-month follow-up assessment. PCIT seems to be an efficacious intervention for Puerto Rican families who have young children with significant behavior problems.

Genetic interaction analysis for DRD4 and DAT1 genes in a group of Mexican ADHD patients.

Attention-deficit hyperactivity disorder (ADHD) is a clinically complex and multifactorial psychiatric disorder of inattention, hyperactivity and impulsivity. Family, twin and adoption studies suggest a genetic influence in the etiology of ADHD. Two variable number of tandem repeats (VNTR) polymorphic systems have been frequently associated with this disorder: the 7 repeat (R) allele in exon 3 of the dopamine receptor D4 (DRD4) and the 10R allele located in the 3' untranslated region (UTR) of the dopamine transporter (DAT1). We conducted a case-control association study between ADHD and these polymorphisms in a group of adolescent inhabitants of the metropolitan area of Mexico City. In addition, we evaluated the interaction between these genes, the disorder and its associated psychiatric comorbidities. No positive association between ADHD and the 7R allele of DRD4 or the 10R allele of DAT1 was observed; however, compared to controls, patients with internalized comorbidities had a lesser frequency of genotypes with the 7R allele of DRD4 and the 10/10 genotype of DAT1. A logistic regression analysis showed that the simultaneous absence of the 10/10 DAT1 and 7/7 DRD4 genotypes predicts membership to the group of ADHD patients with internalized comorbidities (e.g. anxiety, depression). Our results highlight the importance of cross-ethnic research and the possibility of a distinct genetic basis that underlies the type of comorbidities associated with ADHD. This result should be considered in terms of the study design, and further replication is necessary in an independent sample.

Latino versus Caucasian response to atomoxetine in attention-deficit/hyperactivity disorder.

ABSTRACT We examined the effects of atomoxetine in Latino (n = 108) versus Caucasian (n = 1090) pediatric outpatients (aged 6 to <18 years) during the first 10-11 weeks of treatment in two multicenter, open-label trials. Mean modal doses were not significantly different in Latinos (1.22 mg/kg per day) versus Caucasians (1.27 mg/kg per day; p = 0.22). Both groups showed significant and similar improvements: Mean ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored (ADHDRS-IV-P:I) scores decreased by 54% in Latinos (40.9-18.9; p < 0.001) and by 52% in Caucasians (37.7-18.2; p < 0.001). Other efficacy measures, such as Conners' Parent Rating Scale-Revised: Short Form (CPRS-R:S) and Clinical Global Impressions-ADHD-Severity (CGI-ADHD-S), demonstrated similar and significant decreases. The only significant between-group difference was a greater decrease in the ADHDRS-IV-P:I Hyperactive/Impulsive subscale at weeks 8-11 for Latinos; however, Latinos had higher baseline scores compared with Caucasians. This was not demonstrated in the CPRS-R:S Hyperactivity subscale. There was a significantly higher frequency of CYP2D6 slow metabolizers in Caucasians compared with Latinos. Caucasians reported significantly more abdominal and throat pain, whereas Latinos reported more decreased appetite and dizziness, but no differences in other common adverse events were reported. No suicidal behavior was reported in either group. We found that Latino and Caucasian children with attention-deficit/hyperactivity disorder (ADHD) exhibit a similar pattern of efficacy and tolerability with atomoxetine. The lack of placebo controls was a limitation of this study.

Prevalence of psychiatric disorders among children of different ethnic origin.

The present study assesses the population prevalence of DSM-IV disorders among native and immigrant children living in low socio-economic status (SES) inner-city neighborhoods in the Netherlands. In the first phase of a two-phase epidemiological design, teachers screened an ethnically diverse sample of 2041 children aged 6-10 years using the Strengths and Difficulties Questionnaire (SDQ). In the second phase, a subsample of 253 children was psychiatrically examined, while their parents were interviewed. In addition, teachers completed a short questionnaire about 10 DSM-IV items. Prevalence was estimated using the best-estimate diagnosis based on parent, child and teacher information. Projected to the total population, 11% of the children had one or more impairing psychiatric disorders, which did not differ between native and non-native children. In the total group a clear relationship was observed between the prevalence of psychiatric disorders and gender, parental psychopathology, peer problems and school problems, but not among all ethnic groups separately. This study suggests that the prevalence of psychiatric disorders among non-treated minority and native children in low SES inner-city neighborhoods does not materially differ. However, associated mechanisms may be influenced by ethnicity.

Considering cultural diversity in the management of ADHD in Hispanic patients.

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed less often in Hispanics than in Caucasian patients. Furthermore, Hispanic patients with ADHD are undertreated. The reasons for these disparities are unknown, although difficulties with access to care among this population may offer a partial explanation. In order to improve treatment outcomes in Hispanic patients with ADHD, healthcare providers must reflect on the diversity of the Hispanic population, which consists largely of persons of Mexican, Puerto Rican and Cuban descent. In spite of the fact that Hispanics share a similar language, religion and belief system, there are other significant cultural differences among these subgroups. In addition, English-language proficiency and socioeconomic variables, factors that are known to influence healthcare outcomes, may also differ markedly among Hispanic subgroups. Therefore, strategies to improve the treatment of ADHD in the Hispanic population must include overcoming language barriers by increasing the availability of Spanish-speaking professionals and medical translators and using culturally sensitive diagnostic instrumentation. Furthermore, improving knowledge of cultural practices of particular Hispanic subgroups may improve the therapeutic relationship between patients and clinicians, facilitate the diagnosis of ADHD and allow healthcare providers to make appropriate treatment recommendations.