The Disorder in ADHD Prevalence

ADHD is a disorder that has “a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development”(1). Symptoms are usually seen before the age of 7, and the patient has to show disruption of functioning in 2 environments (eg. Home and school), and have disruption in educational, social or occupational settings. As children are the ones that are usually diagnosed, they can appear fidgety, distracted, hyper and confused. One odd thing about the appearance of the disorder is that at one point or another, children usually look and feel this way. This has led to a hypothesis of over-diagnosing this disorder. However, that has been said so far only in the United States. There are many counties that have never even heard of the disorder. This brings up the idea of prevalence rates for ADHD, and my question is, why do the prevalence rates appear so different in many parts of the world? I feel that there are several reasons, and they include the idea of a culture bound syndrome, parenting style, socio-economic status of the country and its people, and the criteria used for diagnosis.
The general prevalence for ADHD is 3-7 percent in school age children. Usually, the disorder carries on into adulthood and people with ADHD have a hard time keeping a job, maintaining family, and maintaining a smooth life. It is most commonly seen in the Americas and Europe, and there are limited prevalence of it in other regions of the world such as Asia and the Middle East (2). One thing these regions have in common is the level of development. Most of the countries in these regions are first world; as such, all the countries in these regions have a similar structure and lifestyle. Generally, the societies are orderly, and anyone who is slightly out of order may be looked upon more closely. Due to this, ADHD can be argued to be a culture bound syndrome.
A culture bound syndrome is defined as a “recurrent, locality-specific pattern of aberrant behavior and troubling experience” by the DSM-IV-TR(1). Generally, these syndromes occur in specific cultures. The people with culture bound syndromes are seen as “deviating from the supposed cultural ‘norm’.” (3)  First world counties can be considered to have a defined culture where things are very systematic and rule based, compared to the generally unruly structures of third world countries. As an individual who was has lived in both Bangladesh (a third world country) and the U.S., I can say personally that the cultures are very different. This difference is not only due to the language and regional difference, but just the order of things. For example, just take the two methods of driving and crossing the streets. In the U.S. people generally obey the light systems and wait for the light to turn green before moving forward from the stop sign. Also, people stop walking if the “Don’t Walk” sign comes up. This isn’t so in Bangladesh. While there is a traffic system, it is more often than not ignored. Even when the lights are green and cars are zooming by, people walk through the middle of the street, and the cars zoom by, red light or green. Looking from that example, it may be understandable why people in Bangladesh or from that region of the world might consider what the American culture would consider to be a child with ADHD, a child to be just a very active normal child.
Also feeding into the idea that ADHD may be a culturally prevalent disorder are parenting methods in the U.S and westernized nations compared to those of poorer nations such as those in the Middle East, Africa and the Indian subcontinent. Majority of families in those regions follow strict patriarchal rules, where the mother is the major nurturer and the father is the breadwinner. Also, parents are fairly nonchalant about the hyperactivity of their children. However, in westernized nations, majority of the families have both parents working, and the child is usually left with a babysitter, nanny, grandparent, etc., until the child is old enough for school. From this, it has been indicated that the child can become lonely, and lack parental warmth. As such, they release that loneliness by acting aggressively towards parents and peers. Parents have less time to devote to their children, and if a child is hyperactive, parents may become easily frustrated with their “unruly” child and can “make attempts to control their children’s behavior and engage in more power assertive discipline” (4). However, parents in third world countries generally have more patience with their children and thus there are fewer attempts to control their children’s behavior. Parenting styles in less developed countries give more lax to children who are hyperactive/inattentive so that the possibility of ADHD is overlooked because in that culture, the child is considered “normal”. As such, people have different criteria for ADHD in other countries.
According to the DSM, there are 3 sub-types of ADHD. There is the Hyperactive/impulsive subtype, the inattentive subtype, and the combined subtype. The hyperactive/inattentive subtype generally shows symptoms of being very hyper with low impulse control; the inattentive subtype is generally not focused and often looks “dreamy”; the combined subtype shows symptoms that are both hyperactive and inattentive. The general criterion to be diagnosed as one of these is that an individual must show 6/9 symptoms in the category for hyperactive/impulsive and inattentive, and 6/9 out of both categories to be considered a combined type (1). However, not everyone uses the DSM, and it has been argued that sometimes such straightforward methods cannot be used to diagnose a person. For example, if a person has 5/9 symptoms in both categories, with a total of 10 symptoms out of 18, they cannot officially be diagnosed as ADHD, so the official prevalence decreases according to these standards which may skew the actual prevalence rate for ADHD. Also, in diverse populations, people may account the symptoms as something in the environment and non-medical (5).
It has been shown that in diverse populations such as the one in the United States, ethnicity plays a big role on the diagnosis or non-diagnosis of ADHD. For example, a study was done in the 1970s which used teachers ratings for comparing ADHD prevalence between ethnic minority and white elementary school children. It was found that African American children’ hyperactivity levels were highest of all (even than white children) but researchers states that the “symptoms are a result of living in chronically stressful and unpredictable environments” (6) and that in the end, only 28% of the at-risk African American children received treatment compared to the 51% at risk Caucasian children. This is probably because in general, the socioeconomic status of African Americans and ethnic minorities in general are lower than those of Caucasians, and thus, ethnic minorities have greater levels of stress which can make children “act out” and be aggressive and defensive and active as a conditioned reaction to the constant stresses of their environment. However, while the symptoms can be accounted for by the environment, it is unfair for those children at risk or undiagnosed by ADHD not receiving children. Also because the minority groups have a lower SES, they end up with poorer insurance which prevents them from receiving proper care and medication (5)
ADHD is a very complicated disorder. No one is sure exactly why its prevalence rates have such heterogeneous effects, although culture and geographic location may play a part in it (2). It can also be due to parenting styles – if the parent views the hyperactivity or inattentiveness as normal, the idea of ADHD does not occur to them. Also, different criteria used for diagnosing ADHD can also have mixed results on the disorders prevalence. In my opinion, ADHD will rise alongside the rise of westernization, which has specific social norms that if you do no live up to, you will be considered abnormal and possibly “ill.”


References
(1) American Psychiatric Association, The Diagnostic and Statistic Manual for Mental Disorders, American Psychiatric Association, 2000
(2) Polanckzy, G.,Silva de Lima, M., Horta, B.L., Biederman, J., and Rohde, L.A. The  Worldwide Prevalence of ADHD: A systematic Review and Metaregression Analysis, The American Journal of Pychiatry; June 2007, 942-948
(3) Kopeic, Rob. Culture Bound Syndromes <http://faculty.oxy.edu/tobin/honors/rob/robdraft3.html, accessed January 26, 2009
(4) Hurt, E.A., Hoza, B., Pelham, W.E., Parenting, Family Loneliness, and Peer Functioning in Boys with Attention-Deficity/Hyperactivity Disorder, Journal of Abnormal Child Psychology vol. 35, Springer Science, 2007, 543-555
(5) Comer, Ronald J. Abnormal  Psychology, 6th edition, Worth Publishers, 2007
(6) Mattox, R., Harder, J. Attention Deficity Hyperactivity Disorder (ADHD) and Diverse Populations, Child and Adolescent Social Work Journal, Vol. 24, No.2, April 2007, 195-207