ADHD and Culture
Culture is an extremely important part of every person’s life and nobody can completely escape its influence, whether one’s native culture or adopted culture. Indeed, culture is extremely powerful and shapes multiple aspects of society, as well as the individual. Although we feel ourselves unique (of course some cultures encourage this feeling more than others, such as individualistic cultures in comparison to collective cultures), we are inextricably tied to our culture and influenced by it in ways of which we may not even be conscious.
Although most people are aware of how culture may influence one’s taste in food and music, cultural influence goes far beyond this. In fact, culture shapes the way we think and even our perceptions of reality. A branch of psychology, known as cultural psychology or cross-cultural psychology is dedicated to studying how culture shapes our psychological processes and perceptions. One aspect of cultural psychology is the study of how culture affects mental health, as well as the influence culture has over our perceptions of mental health.
Cultural psychology, reveals how culture provides a framework or context which determines how mental disorders are expressed. Indeed, certain mental disorders may be more prevalent in certain cultures or even unique to a particular culture. That is, a mental disorder may exist within one culture only.
Mental disorders which tend to be unique to a particular culture are known as culture-bound syndromes. Hikikomori, koro, and anorexia nervosa are cited as examples of culture-bound syndromes. Hikikomori, which appears to be unique to Japanese culture, refers to a mental disorders in which the primary feature is extreme social withdrawal, while koro is culture-bound syndrome found in South and East Asia which is a phobia or extreme fear that one’s penis will shrink inside one’s body. Eating disorders, such as anorexia nervosa and bulimia are more prevalent in Western cultures or where Western-cultural influence is more abundant, leading some researchers to claim that they are, in fact, culture-bound syndromes.
Mental disorders which are found across the world regardless of culture are known as universal syndromes. Researchers purport that universal syndromes tend to have a biological root, meaning that culture place less of a role. Nevertheless, perceptions of these particular disorders by members of a certain cultures may be uniquely influenced by said culture. Universal disorders include depression, schizophrenia, social anxiety disorder, and bipolar disorder, for example.
ADHD appears to be a universal syndrome, although perceptions of the disorder or the degree to which it is pathologized or normalized varies widely across cultures. Although perceptions and/or attitudes toward other mental health disorders (such as major depressive disorder or schizophrenia, for example) may vary somewhat across cultures, perceptions and/or attitudes towards ADHD may vary much more widely than other mental health disorders. This may make ADHD unique in this regard.
Nevertheless, there are mental health professionals and researchers who claim that ADHD is simply a cultural construct. They cite the lack of “specific cognitive, metabolic, or neurological makers and no medical tests for ADHD” to support this assertion (Timmi and Taylor, 2004). Eric Taylor, a psychiatrist in the UK, argues that ADHD is a cultural construct. He states that there are “no specific cognitive, metabolic or neurological marker and no medical tests for ADHD.” Although this may be accurate to some degree, this is the case for most all mental disorders. Indeed, mental disorders may not be identifiable via standard medical tests, such as blood tests or tissue biopsies.
Taylor reports that brain imaging studies are not able to determine if there are abnormalities in the brains of children with ADHD and that any differences found are inconclusive; that is, the differences cannot be said to be the cause of the ADHD symptoms. Furthermore, comorbidity is very high in people with ADHD; therefore, it could be argued that many other factors cause ADHD symptoms observed. Perhaps, ADHD-like behaviors are better explained by other disorders, according to Taylor.
Taylor believes that the only way to explain the rise in the prevalence of ADHD is by a shifting cultural perspective. He believes that changes in culture have led to an increase in ADHD diagnosis. For example, there are many factors that adversely affect the mental health of children and people in general. This includes breakdown in families (more single-parent families), parents less willing to discipline their kids (i.e., teach appropriate behaviors), schools which are over-stretched, and an economic system which emphasizes individuality and competiveness. Taylor believes that many families lead a “hyperactive lifestyle,” as well, which leads to children learning hyperactive behavior. Taylor concludes, that all of this combined may be more difficult to change than to simply create a disorder and blame the child.
Taylor goes on to argue that a medical model for ADHD is not helpful. He believe it simplifies the problem and leads to doctors, parents, and teachers disengaging from social responsibility. Instead they come up with a “cultural disorder” in which they purport to have a cure.
On the other side of the argument Timimi believes that ADHD is neither a genetic disorder nor a social construct, but rather the interaction of the two which results in ADHD. Timimi cites research which points out that there are difference in brain structure, especially in regards to the dopamine system. Furthermore, he states those from all socioeconomic statuses are affected by ADHD, which he believe supports the idea of it being an actual disorder. He goes on to state that two studies 20 years apart in the UK showed that rates of ADHD have been mostly stable over time.
In short, he admits that social factors may play a role, but he does not believe that ADHD can be relegated to a cultural or social construct. He believes that it is more complex than that. Timimi also states that in the UK, ADHD is more likely to go underdiagnosed; however, he acknowledges it can be over diagnosed in some cultures, such as in the US.
However, some research has found a correlation between socioeconomic status and ADHD, with those coming from a lower socioeconomic status having higher rates of ADHD. In fact, financial difficulties was found to be the strongest predictor of ADHD. This, however, does not necessarily mean that ADHD is not an actual disorder and simply the result of a disadvantage upbringing. For example, people from lower socioeconomic status are at greater risk for many disorder, such as diabetes and schizophrenia (Russel et al., 2015).
What is more likely is that there is an interplay between environment, genetics, as well as psychological and sociological factors which either leads to the development of ADHD symptoms or an exacerbation of the symptoms. Furthermore, those from disadvantage backgrounds may not have timely access to appropriate treatment which may cause ADHD to worsen, as well further lead to other complicated problems, such as depression, anxiety, or substance abuse (Russel et al., 2015).
Although ADHD is found across multiple cultures, diagnostic rates vary widely. For example, rates in France……USA…..Korea…… This variability in diagnostic rates is believed to be due differences in what is regarded as normal childhood/adolescent behavior versus abnormal behavior across various cultures. For example, diagnostic rates in Mexico are believed to be lower, as Mexican culture tends to be more tolerate of behaviors that may be considered ADHD, such as hyperactivity and impulsivity. On the other hands, cultures where children are expected to sit quietly and inhibit their impulses, such as in the USA or Japan, diagnostic rate are often higher. Indeed, misdiagnosis is always a possibility. Some cultures may result in under diagnosis of ADHD (such as in Mexico) or over diagnosis (such as in the USA).
In addition to cultural influence on perceptions of ADHD, culture may have an influence on a society’s propensity to medicate ADHD. Although the United States consume about 80% of the world’s Ritalin, the International Narcotics Control Board reported that Iceland consumed slightly more Ritalin per capita than the United States. Furthermore, the consumption of Ritalin has increased a great deal all across the globe in multiple nations surveyed. The one exception was Israel, where consumption rates dropped slightly (Singh, 2008. One may deduce that the increase in consumption or Ritalin across the globe points toward greater awareness of ADHD and pharmacological treatments.
However, even within a particular culture diagnostics rates can vary. In the United States, Reid revealed in his study that ADHD rates tend to be higher in certain ethnic groups (1998). For example, ADHD rates in African-Americans and Hispanic-Americans are higher than rates amongst Caucasians. Although it is possible that there are certain conditions within these ethnic groups which may result in higher rates, it may also be possible that ADHD assessment instruments are misleading or invalid for certain ethnic groups (Reid, 1998). Reid points out, however, that socioeconomic status was not taken into account for his study (1998). Therefore, it is possible that the differences in ADHD rates between ethnic groups may have been influenced by socioeconomic status (Reid, 1998). According to Russell, ADHD rates are often higher in those from lower socioeconomic status (Russell, 2015).
ADHD rates in Thailand appear to be somewhat lower than in Western cultures; however, studies on ADHD in Thailand are very limited. Barkley, et al. reported that ADHD rates are lower in Thailand due to cultural factors which train children to speak quietly in public and encourage obedience to authority figures (1987). Although is some truth to this, this would not necessarily identify children with ADHD, Inattentive type (since these children are rarely disruptive).
Studies have shown that the prevalence of ADHD varies widely across cultures, with a worldwide prevalence estimated to range between 2.2% and 17.8% (Skounti, Philalithis,& Galanakis, 2007). However, this variability in the rates of ADHD could possibly be explained by the reality that the perception of ADHD can vary across cultures (Bussing, et al., 1998). Furthermore, “whether individuals and communities perceive the behaviors associated with ADHD as problematic depends on a given culture’s acceptance of the problem behaviors associated with ADHD and their occurrence in children (Al Azaam, 2011).”
According to one study, Korean culture view symptoms of ADHD in children as a failure of teachers and parents. Therefore, Koreans may fail to recognize symptoms of ADHD as a disorder, but rather blames themselves—viewing themselves as inadequate parents or teachers. As such, parents and/or teachers are often reluctant to seek out assistance for dealing with children with ADHD (such as from psychologists and counselors) out of fear of being judged negatively by other family members or colleagues (Hong, 2008). Indeed, Singh states that ADHD is poorly understood in Korea, combined with a culture which places blame on parents and educators, it is logical that rates of ADHD reported in Korea would be lower when compared to other countries. However, in fact, lower rates of ADHD in Korea may be the result of perception rather than actual lower rates (2008).
ADHD rates in Thailand may be lower due to multiple reasons. For example, there may be less awareness amongst Thai society of ADHD as a disorder, leading Thai people to regard symptoms of ADHD as either normal child or adolescent behavior or as behavior that is willingly disruptive. Additionally, children and adolescents who display such behaviors may be regarded as “stubborn,” “bad,” or “stupid.” That is, children with ADHD in Thailand may be mislabeled rather than slotted for treatment, leading only to the appearance of lower rates instead of actual lower rates.
On the other hand, it is possible that there are in fact lower rates of ADHD in Thailand due to certain factors, such as culture and/or family upbringing. Indeed, culture has a strong influence on the expression of various mental disorders. However, it is also possible that perceptions of what constitutes ADHD or awareness of ADHD in Thailand gives the appearance of lower ADHD rates. Culture, perception, and actual pathology interact—leading to what is reported as ADHD rates in any given society.
Thus, to completely understand how to identify and treat ADHD, it must be studied from within a cultural perspective. Research suggests that ―culturally-relevant factors, like beliefs and values regarding child behavior, impact the way members of various ethnic and cultural groups view and respond to problematic behavior in children (Al-Azzam, 2011).
The focus of the present research is to examine rates and perceptions of ADHD in Thailand in order to gain a clear picture of ADHD in Thailand. One way to examine how culture may influence rates of ADHD is to examine parental and educators’ perceptions of what should be deemed normal problematic behavior or behavior resulting from pathology.