Challenging Case: Health Care Professionals as Cultural Brokers for a Boy From Central America With Attention-Deficit Hyperactivity Disorder and Trauma and Stressor-related Disorder

CASE:

“Javier” is an 8-year-old boy with a complex psychosocial history presenting for a developmental-behavioral pediatrics consultation because of concerns regarding hyperactivity (affecting safety) and developmental delays, including “lack of independence.” He is not yet toilet trained and in his mother's words, “he has the mindset of a child that is much younger than his actual age.” Javier's family emigrated to the United States from Central America a year ago to seek asylum. During his family's journey to the United States, Javier and his mother were kidnapped and sexually assaulted. On settling into the United States, Javier was evaluated by his local school district and qualified for specialized services. His mother is not aware of what support he receives at school and is concerned that he is not making sufficient progress. He has not previously received developmental therapies or psychosocial interventions.

Javier has demonstrated developmental delays, including reduced reciprocal social communication skills, since birth. His mother shared that he was not able to attend school in Central America as “no schools had the resources to educate him.” He began speaking around age 5 years and currently communicates using phrased speech. There have been long-standing safety concerns related to his impulsivity, including wandering, which first emerged in his early toddler years. His hyperactivity predates his history of trauma and sexual abuse. Currently, he demonstrates intermittent physical aggression toward family members. He is interested in fire and has set objects on fire in the home. He is also drawn to placing items in electrical outlets, which has resulted in multiple self-electrocutions.

Javier does not have medical insurance but receives limited health coverage through a program for uninsured residents with low income. He was evaluated by a psychiatrist and prescribed 2 medications, although his mother does not know the names of the medications prescribed. Review of psychiatry records indicated that he was prescribed guanfacine extended-release and amphetamine and dextroamphetamine salts extended release. These medications led to improvements in his behavior regulation, although he was not able to take these medications consistently because of cost.

Javier's developmental evaluation included assessment of his cognitive, adaptive, and social communication skills in his native language. His diagnostic evaluation yielded provisional diagnoses of autism spectrum disorder with accompanying speech and intellectual impairment. Psychiatric diagnostic impressions included complex attention-deficit/hyperactivity disorder in the context of his significant trauma history. His mother did not have prior conceptualization of developmental or psychiatric diagnoses, and psychoeducation through a cultural lens was provided. What are your next steps in partnering with Javier's family as they navigate medical and educational systems following their recent arrival to the United States?

* “Javier” is a pseudonym.

Jeffrey D. Shahidullah, PhD

Because of overlapping symptoms and “tangled roots,”¹ teasing out whether symptoms stem from attention-deficit hyperactivity disorder (ADHD), trauma, or both can be difficult and nuanced even for seasoned clinicians. Trauma affects the development of a growing brain, particularly areas that deal with a child's memory, attention, behavior, and emotional processing, making post-traumatic stress disorder (PTSD) symptoms look like ADHD symptoms.² Trauma can make ADHD symptoms worse, and ADHD can exacerbate effects of trauma. Complicating this picture is the presence of a bidirectional relationship between ADHD and PTSD whereby individuals with ADHD who have trauma histories are 4 times more likely to develop PTSD than controls. In addition, the risk for ADHD in individuals with PTSD is 2 times more than in controls.^3,4 Past histories of trauma can activate fight-or-flight responses and can skew perceptions of the actions of others as negative and hostile, causing children to act out in ways that appear impulsive, agitated, and aggressive. These youth can end up receiving an unwarranted oppositional defiant disorder diagnosis.⁵ When aggressive and hostile actions occur at school, these children are at high risk of stigmatization, suspension, and expulsion.

Javier demonstrated elevated levels of hyperactivity that predate the trauma experienced on his families' migration to the United States, but how much do we know about his trauma and adverse childhood experience history before this? Unfortunately, children who live in areas with high concentrations of community violence and poverty often have higher rates of ADHD diagnoses, and signs of trauma may be overlooked. This highlights the importance of conducting culturally sensitive and trauma-informed assessments. It can be helpful to incorporate a trauma-based measure (e.g., PTSD University of California, Los Angeles (UCLA) Index⁶) into the diagnostic evaluation to tease apart ADHD and PTSD symptoms.

Recommendations for treatment of ADHD and PTSD symptoms should be individualized based on the needs, access, and readiness of the child and family. Culturally sensitive psychoeducation helping the mother understand the role of trauma and ADHD is a first step. For PTSD, trauma-focused cognitive-behavioral therapy⁷ may be most effective particularly when parents are involved to understand and support the skills that their children are learning. For ADHD, behavioral skills training focused on the parents' role in supporting skills uptake in the child through rewards and contingency management is recommended. In sequencing ADHD versus PTSD treatments, focusing on ADHD may reduce attention and behavioral symptoms enough to allow a patient to be receptive to trauma-focused therapies. Addressing ADHD and PTSD concurrently is another option.

Courtney Kates, MD

Stimulants are the first-line medical treatment for attention-deficit hyperactivity disorder (ADHD).⁸ There is evidence that treatment of ADHD with stimulants can reduce aggression, antisocial behavior, and the risk of being diagnosed with major depressive disorder, oppositional defiant disorder, and anxiety disorders.⁹ In addition to improving quality of life and reducing functional impairment, stimulants may also reduce substance abuse, accidental trauma, and suicidal behavior.¹⁰

Evidence-based psychopharmacologic options for post-traumatic stress disorder (PTSD) in children are less clear because of limited clinical trials in this population. There are no Food and Drug Administration (FDA)–approved medications for PTSD.¹¹ Selective serotonin reuptake inhibitors (SSRIs) are first-line medical treatment in adults, although only sertraline and paroxetine are FDA approved.¹² Several adult studies indicate that SSRIs can improve PTSD symptoms with modest effect sizes,¹² whereas pediatric trials have not found SSRIs more effective than placebo.¹¹ Prazosin initially appeared to improve PTSD symptoms in adults; however, a recent large trial in veterans did not find it effective, leading to varying recommendations regarding its utilization.¹² Medication for PTSD in children should still be considered and take into account functional impairment, comorbidities, and symptoms.¹¹ SSRIs may benefit children with anxiety or depressive disorders, guanfacine may benefit children with hyperarousal symptoms, and prazosin may benefit children with sleep disturbances and nightmares.¹¹ If there are multiple diagnoses, treatment should target the most favorable risk-benefit ratio for a particular diagnosis while considering resources, social supports, treatment preference, age, and development.¹¹

Javier meets criteria for complex ADHD given his provisional ASD diagnosis with intellectual impairment and trauma history.¹³ He did not have access to psychotherapy because of psychosocial factors including language barriers, underinsurance, limited transportation, and challenges accessing telehealth. His regulation was significantly improved on amphetamine and dextroamphetamine salts extended release, although his use of this medication was inconsistent because of cost. He also benefited from guanfacine extended release dosed in the evenings to support his sleep and behavior regulation. Over time, his mood symptoms and suicidal outcries worsened. Sertraline was added on and titrated to target mood, anxiety, and trauma symptoms.

Natalie Cerda, MD, MPH and Anahi Marquez, MD

Javier's family faced many challenges in navigating the educational and health care systems, including a language barrier. A collaborative multidisciplinary team, comprising his physicians and social workers, applied the concept of cultural brokering to guide and empower his family as they navigated these complex systems. Cultural brokering occurs when health care professionals leverage understanding of a patient's culture and knowledge of health systems to bridge gaps in care. A cultural broker acts as a “go-between” or navigator, advocating on behalf of the patient to ensure their needs are met.^14–16 Javier's medical team put this into action by attending his Individualized Education Program meeting to support his mother in advocating for his educational needs. The social work team collaborated with nonprofit organizations to assist the family in covering the cost of his prescriptions and in securing housing.

Embracing principles of cultural humility is crucial to building trust and effective cultural brokering. Cultural humility involves self-reflection and understanding of power imbalances that are present in physician-patient interactions. Cultural humility is practiced when clinicians adopt a humble approach, recognizing that patients are the experts of their own culture and that clinicians have valuable lessons to learn from each and every patient.¹⁷

The Cultural Formulation Interview, as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, was used to deliver psychoeducation through a culturally informed approach.¹⁸ As his mother had no prior knowledge of autism, it was crucial to first understand her perspective and then explain the diagnosis using her own words to facilitate a clearer understanding. When asked what Javier's diagnoses of autism and intellectual disability meant to her, his mother explained that it meant he has “another way of seeing the world.” When asked what health care professionals should understand when caring for immigrant populations, Javier's mother emphasized the importance of asking families about their “necessities, because the hardest thing is not having a home.” Addressing social drivers of health, including housing insecurity, was a vital step in his care and building “la confianza” or trust with the family. Ultimately, it is not just about providing medical care, but about walking with families in their journey, providing support and guidance every step of the way.

Elizabeth Diekroger, MD and Jason Fogler, PhD

Javier's case illustrates the need for improved access to pediatric behavioral health treatment for low-income, immigrant, and populations with a dominant language other than English. Children of immigrant families are at higher risk for stressors affecting mental health such as family separation, stress surrounding immigration status, violence, racism, low socioeconomic status, and acculturative stress.¹⁹ They may face several challenges including inadequate health care coverage, language barriers, stigma, and lack of culturally sensitive clinicians, making them less likely to receive mental health treatment.¹⁹ Key Action Statement 4 of the Complex attention-deficit hyperactivity disorder (ADHD) Practice Guideline emphasizes the importance of making clinical decisions in partnership with the family and regarding cultural context.¹³ This case highlights how ADHD cannot be treated in isolation as it exists within the context of familial beliefs and cultural expectations—particularly for families who are not part of the dominant culture. It is imperative for clinicians to partner with families to develop a treatment plan that is feasible, acceptable, and just.