ADHD in Thailand

By Eric Mason, LPC, LCAS

Chapter I

Introduction

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:

1. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
2. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

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.

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or doing other activities (e.g., overlooks or misses details, work is inaccurate).
2. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy).
3. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
4. Often does not follow through on instructions and fail t finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
5. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
7. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
8. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
9. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
10. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconcsistet with developmental level and that negatively impacts directly on social and academic/occupational activities:

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.

1. Often fidgets with or taps hands or feet or squirms in seat.
2. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in the others situations that require remaining in place).
3. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless).
4. Often unable to play or engage in leisure activities quietly.
5. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by other as being restless or difficult to keep up with).
6. Often talks excessively.
7. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
8. Often has difficulty waiting his or her turn (e.g., while waiting in line).
9. Often interrupts or intrudes on others (e.g., butts into conversations, fames, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
10. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
11. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
12. There is clear evidence that the symptoms interfere with, or reduce the quality or, social academic, or occupational functioning.
13. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

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:

1. To determine if measures typically used to identify ADHD in Western cultures, such as the Connors 3 and TOVA, are culturally biased.
2. To determine if the Connors 3 correlates with the TOVA across Thai and Western children.
3. To determine how Thai children perform on the TOVA compared to their Western counterparts.
4. To determine what perceptions of ADHD are held by Thai parents and teachers as compared to Western parents and teachers.
5. To investigate if Thai children are more likely to be underdiagnosed, as they may be more likely to exhibit ADHD, Inattentive Type rather than hyperactive type (since Thai classrooms may be more structured and Thai culture requires more obedience to following rules).

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

ADHD, Inattentive Type

ADHD, Hyperactive Type

ADHD, Combined Type

Conduct Disorder

ODD

Conners 3

TOVA

Thai

Western

DSM-5

Pathologize

Cultural-Specific Disorder

Antisocial Personality Disorder

Culturally Bound

Bio-psycho-social-cultural