By Eric Mason, LPC, LCAS
There are few psychological disorders which are as well known to the general public (at least in most Western Countries) as Attention-Deficit/Hyperactivity Disorder (ADHD). Likewise, there are few disorders that are as controversial as ADHD. In the debate of ADHD, people tend to fall into two different camps—those who deny the disorders existence, citing lack of self-discipline, poor parenting, or personality factors as the cause of ADHD-like behaviors, and those who believe that ADHD is genuine disorder, citing as proof research on brain abnormalities, twin studies, and the effectiveness of medications in reducing ADHD-like behaviors.
Furthermore, adding to the debate, some view ADHD as a social or cultural construct and believe that ADHD-like behaviors are representative of normal, natural behaviors of youth that have been pathologized (mostly by Western mental health professionals adhering to DSM-5 criteria). Indeed, perceptions of what may be deemed as inappropriate or dysfunctional behaviors usually varies from culture to culture. It has been well documented that some psychological disorders are, in fact, culturally bound.
Research has demonstrated that the prevalence of ADHD varies across cultures. For example, rates of ADHD in France tend to be lower when compared to rates in Germany, which, of course, is just across the border and one of France’s neighboring countries. This is not an isolated example. Rates of ADHD are different across practically all countries.
Most likely there are many reasons why ADHD varies across different countries and cultures. For example, differences in diagnostic tools used by clinicians, attitudes and perceptions towards ADHD, familiarity with the disorder itself, and access the proper mental health care may all play a role in the diagnostic variability of ADHD across different countries and cultures. Most certainly, the culture itself would also play a role. For example, some cultures may define certain behaviors as problematic and abnormal, while other cultures may regard these same behavior as normal. Clinicians working within cultures that have the tendency to pathologize certain behaviors may be more likely to diagnose children and adolescents with ADHD.
Like many psychological disorders, the causes and expression of ADHD are full of complexities. Nevertheless, most research points towards a bio-psycho-social-cultural explanation of ADHD. Although this explanation may not be simplistic to understand, it incorporates the arguments of both camps mentioned above and provides a more accurate and meaningful explanation of ADHD. Ultimately, both camps may be right and wrong at the same time. That is, ADHD may be a real disorder that is either over or underdiagnosed depending on which culture is in question.
As mentioned above, ADHD affects people across all cultures and backgrounds—albeit at different rates. In the U.S. prevalence rates are estimated at between 5% and 10% for children and 2.5% for adults. According to the DSM-5, males are twice more likely to have ADHD in childhood than females and six times more likely to have it in adulthood. However, other research has found that females are just as likely to have ADHD as males, though females may be more likely to manifest inattentive features than hyperactive and impulsive features of ADHD.
Although ADHD is found across multiple cultures, prevalence rates are not equal across cultures. In regards to cultural-related diagnostic issues and ADHD, the DSM-5 states that
differences in ADHD prevalence rates across regions appear attributable mainly to different diagnostic and methodological practices. However, there also may be cultural variation in attitudes toward or interpretations of children’s behaviors. Clinical identifications in the United Sates for African American and Latino populations tend to be lower than for Caucasians populations. Informant symptom ratings may be influenced by cultural group of the child and the informant, suggesting that culturally appropriate practices are relevant in assessing ADHD (DSM-5).
Therefore, it is important to understand differences across cultures when assessing for ADHD.
The DSM-5 describes the essential feature of attention-deficit/hyperactivity disorder as a “persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.” Presently, there are three sub-categories of ADHD listed in the DSM-5. They are as follows: ADHD, Combined Presentation; ADHD, Predominantly Inattentive Presentation; ADHD, Predominantly Hyperactive/Impulsive Presentation. Furthermore, ADHD may be specified as mild, moderate, or severe.
Below is the diagnostic criteria for ADHD as presented by the DSM-5:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
There are many problems that may directly result from the dysfunctional behaviors of ADHD. Children with ADHD often perform poorly in school, while adults may suffer occupational difficulties. Indirectly, children with ADHD appear to be more likely to develop other disorders, such as substance use disorders, conduct disorders, antisocial personality disorder, depression, and anxiety. In addition to mental health problems, children with ADHD are more likely to be injured in accidents and may even be more likely to develop obesity.
Nevertheless, it is important to keep in mind that some positive attributes may result from ADHD. For example, people with ADHD are often creative, enthusiastic, and energetic. However, appropriate guidance is usually still needed to foster these positive attributes in people with ADHD.
Those who advocate for appropriate treatment of ADHD site the potential for lifelong difficulties if not addressed early. Like most psychological disorders, research has shown the various types of treatment are effective in reducing ADHD symptoms. Treatments for ADHD include medications, behavioral management techniques, parenting classes, one-on-one counseling, as well as teacher/school involvement. Usually, a combination of the aforementioned treatments is the most effective approach; however, some research had indicated that medication treatment alone may be more effective as a standalone treatment for clients with ADHD and comorbid Conduct Disorder and/or ODD.
There has been little research into the prevalence of ADHD in Thailand. Indeed, in Thailand, the general public does not seem to be as aware of ADHD as in Western countries. In Thailand, hyperactive/impulsive children are more likely to be regarded as stubborn, defiant, or simply, bad kids, while children who are inattentive may be viewed as aloof, spacey, or at worst, stupid. In addition, it is possible that ADHD-like behaviors are regarded as normal age-appropriate behaviors in Thailand. For example, a study in Mexico found that teachers were more tolerant of ADHD-like behaviors than their American counterparts.
This misunderstanding of ADHD may lead to greater negative consequences for children with ADHD in Thailand. The mental health field in Thailand continue to lag behind Western countries and Thai public schools usually lack specialized support staff, such as school counselors, psychologists, or special education teachers. Therefore, the potential for Thai students with treatable ADHD to slip through the cracks and not receive appropriate treatment is very high. At best, such students may not reach their full potential. At worst, they may fail and ultimately drop out of school.
Purpose of the Study
The primary purpose of this study will be to analyze ADHD in Thai students in contrast to ADHD in Western students. In so doing, the study will investigate if Thai students and Western students experience ADHD at the same rate and in the same way. This will address some controversial aspects of ADHD; namely, to what extent is it a cultural construct. Furthermore, perceptions and attitudes towards ADHD will also be examined. As such, the purpose of this study will include the following:
Significance of the Study
Presently, there has been little research on ADHD in Thailand. The use of ADHD measures, such as the Conners 3 and TOVA, have not been studied in Thailand. Furthermore, perceptions of ADHD and cultural-specific attitudes toward ADHD in Thailand have not been looked at in previous studies.
Overall, this study would improve understanding, as well as awareness of ADHD in Thailand. In so doing, it would seek to improve diagnostic measures for ADHD in Thailand by researching assessments tools (the Conners 3 and TOVA) commonly used in the West and their applicability in Thailand. This would serve to improve accuracy of diagnosis of ADHD in Thailand. Furthermore, cultural-specific attitudes will be analyzed in order to establish if there are unique aspects of how ADHD is viewed and/or experienced in Thailand.
This results of this study could be profoundly useful in improving the lives of children and adolescents in Thailand. In improving the general understanding of ADHD in Thailand, it would contribute to ensuring that Thai youth with ADHD may have better access to treatment for ADHD. This would allow such youth to do better in school and may contribute to reducing dropout rates. In the long run, improving access to treatment for ADHD in Thailand would play a part in improving Thai society as a whole, since students with ADHD would be more likely to achieve higher educational levels.
Definition of Terms
ADHD, Inattentive Type
ADHD, Hyperactive Type
ADHD, Combined Type
Antisocial Personality Disorder