Knowledge of ADHD in Thailand

Abstract: The current research examined the level of knowledge of ADHD in Thailand. Knowledge of ADHD is important, as lack of knowledge my lead serve as a barrier to treatment.  The study found that the Thai sample answered 43.59% of the KADDS correctly. The percentages were compared to previous studies other countries. Although Thais scored lower when compared to Western countries, the difference was not statistically significant. However, Thais scored higher when compared to samples in Saudi Arabia and Vietnam and the difference was statistically significant between these samples and the Thai sample.

Introduction

            The primary purpose of the study was to determine the level of knowledge and awareness of ADHD amongst a sample Thais ages 18 to 75 living in Thailand. The research instrument used for this study, the Knowledge of Attentions Deficit Disorder Scale (KADDS), measures the following factors: misconceptions regarding the treatment of ADHD, misconceptions regarding symptoms and diagnosis of ADHD, as well as knowledge of associated features (general information about the causes, overall nature of ADHD, and prognosis of the disorder) (Sciutto & Feldhamer, 2005) . Therefore, the study identified the level of knowledge of ADHD amongst a sample of Thai adults in the three different areas of knowledge of ADHD described above.

Knowledge and Awareness of ADHD

            Although there is ample research pointing towards ADHD being a legitimate disorder, knowledge and awareness of ADHD is often lacking. It is well established that knowledge and awareness of ADHD varies across countries, cultures, and even sub-cultures within a particular country. For example, Bussing and colleagues (1998) stated that African-Americans’ knowledge and awareness of ADHD was much lower than Caucasians in the United States. Further, having has previous exposure to ADHD would likely result in more awareness of the disorder.

            Bussing and colleagues (1998) reported that 95% of Caucasians had heard of ADHD, while only 69% of African-Americans were aware of the disorder. Furthermore, 70% of Caucasians claimed to know ‘some or a lot about’ ADHD, while only 36% of African-Americans reported knowing ‘some or a lot’ about ADHD (Bussing et al., 1998). According to other research, Mcleod and colleagues (2007) reported that in total 64% of Americans had heard of ADHD, with women and those from a higher socioeconomic status being more likely to have heard of the disorder. Based on information gleaned from a national survey in the United States (National Stigma Study—Children) (n = 1,130), older people and nonwhite racial and ethnic groups were less likely to have heard of ADHD (Mcleod et. al, 2007).

The aforementioned studies point out how knowledge of ADHD between ethnic groups, age groups, sexes, and differing socioeconomic status can vary greatly even within the same country. Therefore, it would be expected that knowledge and awareness of ADHD could vary even more dramatically across different cultures and countries. This researcher purported that knowledge of ADHD was most likely lower in Thailand than in Western countries, since knowledge of mental health disorders by the general public appears to be limited in Thailand. Research supports that knowledge ADHD is often lower in developing countries (Sciutto & Feldhammer, 2005).

            The Knowledge of Attention Deficit Disorder Scale (KADDS) is often used to measure knowledge of ADHD. The KADDS is a 39 item scale designed to reveal one’s level of knowledge about ADHD. The KADDS was found to have“high internal consistency (.80 < rα < .90) and test-retest correlations for the KADDS scores were moderate to high (.59 < r < .76) (Sciutto & Feldhammer, 2005).” Studies have found the KADDS to be valid. For example, those with previous exposure of ADHD score higher on the KADDS than those without exposure to ADHD (Sciutto & Feldhammer, 2005).

Additionally, cross-cultural studies have found the KADDS to be useful across various cultures. A study of the KADDS in the following nine countries found it to be reliable with high validity: Czech Republic, Germany, Greece, Iraq, the Republic of Korea, Saudi Arabia South Africa, United States, and Vietnam. In addition, the researcher also reported considerable variability in levels of knowledge of ADHD across these nine countries (Sciutto et al., 2016). For example, 70% of those surveyed in Greece seemed to confuse Autistic Spectrum Disorder with ADHD, compared to 30% in the USA and 33% in the Vietnam (Sciutto et al., 2016).

A study in Thailand found that only 19% of teachers answered at least 70% of the KADDS correctly (Muanprasart et al., 2014). A study in India, which used the KADDS to test teacher’s knowledge of ADHD, reported that only 49% questions were answered correctly (the scores of all teachers combined in total, n = 106) (Shroff, Sawant, & Prabhudesai, 2017). Another study which used an instrument designed by the researchers to measure knowledge of ADHD found that the American teachers answered 47% of the questions correctly, while Australian teachers scored 59% correct, overall (Anderson, Watt, & Noble, 2012).

A study in Israel using an instrument designed by the researchers to measure teachers’ knowledge of ADHD reported that only 8% answered correctly questions that described symptoms that met the definition for ADHD, while 58.8% answered correctly questions that described symptoms that partially met the definition for ADHD (Livitan, 2015). This study indicates that the majority of teachers in this survey had some knowledge of ADHD, but lacked a complete or thorough understanding of ADHD.

In addition, perceived knowledge of ADHD may be higher than actual knowledge of ADHD. That is, people may believe they are knowledgeable of ADHD; however, when tested their actual knowledge of ADHD may be much lower. For example, a study in South Africa designed to measure actual knowledge and perceived knowledge of ADHD, which utilized the KADDS and a self-rating scale of their knowledge of ADHD, reported that teachers overestimated their understanding of ADHD (Kern, Amod, Seabi, & Vorster, 2015).

Other studies reported knowledge and awareness of ADHD to vary across South America. Although some studies have reported that there is a high level of awareness of ADHD in Latin American countries, awareness of the biological component of the disorder was very limited. For example, in a sample of 311 research participants (192 participants from the Dominican Republic, 84 participants from Mexico, 35 from Bolivia), over 73% were aware of ADHD as a disorder, but only 11% understood that there was support for ADHD having, at least partially, a biologically component to it. This study points out that there are varying levels of knowledge of ADHD. This is an important aspect of ADHD, as it may affect treatment-seeking behaviors. That is, those who fail to understand the biological aspect of ADHD may be less likely to seek out all treatment options, such as psychotherapy and/or medications (Palacios-Cruz et al., 2013).

Clearly, knowledge of ADHD would affect diagnostic rates and, in turn, treatment for ADHD. Levels of knowledge could lead to both under or over diagnosis of ADHD and, in turn, both under- and overtreatment of ADHD. For example, some argue that awareness of ADHD in Western countries leads to inflated rates of the disorder and, therefore, overtreatment of ADHD with medications (Timmi & Taylor, 2004). However, it may also be argued that under awareness of the disorder in places, such as Thailand, could lead to under-diagnosis of ADHD and under treatment of ADHD.

Although knowledge of ADHD would obviously have an effect on diagnostic rates, other factors, such as culture, as well as perceptions/attitudes, and previous exposure to the disorder could have an effect on diagnostic rates. Cultures where ADHD symptoms are regarded as normal childhood behaviors or where ADHD is regarded as a cultural construct often have lower rates of ADHD, as well (Timmi & Taylor, 2004)..

ADHD in Thailand

As described above, knowledge of ADHD in Thailand appears to be somewhat lower than in Western cultures; however, studies on ADHD in Thailand are very limited (Muanprasart, Traivaree, Arunyanart, & Teeranate, 2014). Barkley and colleagues (2001) 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. Although there is some truth to this, this would not necessarily identify children with ADHD, Inattentive type (since these children are rarely disruptive). In other words, cultural influence in Thailand may result in ADHD taking the form of inattentive type more often than hyperactive/impulsive type.

However, according to Visanuyothin, et al. (2013), rates of ADHD in Thailand are 8.1%. This research used the following methods to assess for ADHD rates in Thailand:

“The first step was done by using a screening test of ADHD with the SNAP-IV, Thai version. The second step was to [conduct] an interview by a child and adolescent psychiatrists using [the] DSM-IV TR criteria [for ADHD]. Thai students graded 1-5 in primary school were recruited for the study. There were 7,188 cases in total (Visanuyothin et. al, 2013).”

According to Visanuyothin and colleagues (2013), rates of ADHD are on par with rates in other parts of the world. In Thailand, rates for ADHD combined type appeared to be highest at 3.8%, while ADHD Hyperactive/Impulsive type were the lowest (Visanuyothin et. al, 2013). Rates for ADHD Hyperactive/Impulsive type being lower would be in line with Barkly and colleagues’(2001) assertion (mentioned above) that the number of reported cases of ADHD in Thailand are lower due to cultural factors which train children to speak quietly in public and encourage obedience to authority figures. As a result, as mentioned above, ADHD may be more likely to present as Inattentive type, which was also supported by Visanuyothin and colleagues (2013). However, another study found ADHD rates in Thailand to be much lower, overall, at 2.2% (Sakboonyarat, 2018). Further research is needed to establish a more accurate prevalence rate of ADHD in Thailand.

Trangkasombat (2009) conducted a retrospective study in which he reviewed the charts of 425 Thai children who were diagnosed as being ADHD by a mental health clinic in Thailand. The purpose of this study was to examine and identify common characteristics of Thai children with ADHD. The chief complaint or reason for which the families were seeking mental health services in 50% of the cases was academic difficulties, and other issues directly related to ADHD. However, nearly one-fourth of the clients presented with chief complaints that the author states are typically unrelated to ADHD, such as aggression and oppositional behavior. However, such symptoms are common in ODD which often co-occurs with ADHD. The article does not address the reason for seeking services for the remaining 25% (Trangkasombat, 2009).

            Out of the 75% mentioned above (with either academic problems or behavioral problems), 46% received a diagnosis of ADHD. The remaining 54% received some other diagnosis. Out of the 425 charts that were reviewed, 202 were diagnosed with ADHD. A diagnosis of ADHD was given according to DSM-IV-TR diagnostic criteria (Trangkasombat, 2009).

The article states that out of the 202 diagnosed with ADHD, 116 were give intelligence tests. Out of these 116, 50% had an IQ below average, as determined by the WISC-III. The research did not identify if the Thai version of the WISC-III was used or if it was normed in Thailand (Trangkasombat, 2009).

Furthermore, Trangkasombat (2009) states that over half of the clients diagnosed with ADHD had comorbid problems, but did not specify what these comorbid problems are, except that 35 clients received medications for problems other than ADHD. It was also specified that 125 clients received stimulant medications, while 77 only received behavioral management treatment. The study did not address the outcomes of any treatments (Trangkasombat, 2009).

The purpose of this study was to identify characteristics of Thai clients with ADHD, as the author points out that ADHD is still a fairly unfamiliar disorder in Thailand. The research points out that most clients who sought treatment (or whose parents sought treatment for their children) exhibited academic difficulties. This is similar to why most Western clients seek out treatment for ADHD (Trangkasombat, 2009).

Furthermore, nearly half of Thai clients with ADHD had some sort of comorbidity, suggesting other psychological issues. Although a Western IQ test was used, the study points out that 116 out of 425 clients in the study had a below average IQ. However, this may be due to cultural bias on the IQ test used (Trangkasombat, 2009).

Although the article may give one a very general idea of clinical characteristics of Thai clients with ADHD, the author did not address the cultural issues surrounding ADHD. From what the author has pointed out, Thai clients with ADHD appear identical to Western clients with ADHD (Trangkasombat, 2009). However, because Western standards were used to diagnose the clients in the study, it could result in them appearing very similar to Western clients.

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). One explanation for the variance in diagnostic rates may be the result of the assessment instruments used to diagnose ADHD. For example, one study found that ADHD rates were higher among Puerto Rican children, when compared to Anglo-American children. However, this study concluded that this may have been the result, because the assessment instrument was based on Anglo American cultural standards which tended to identify culturally normal behavior amongst Puerto Rican children as pathological (Bauermeister et al., 1990).

In addition, the study reported that the cultural background of the assessors (the people who completed a rating scale while assessing children for ADHD) may have skewd the results, as well. For example, Anglo-Americans were more likely than Puerto Ricans to rate children as having problematic behaviors consistent with ADHD (Bauermeister et al., 1990). Variability in the rates of ADHD could also 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 views 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 blame themselves—viewing themselves as inadequate parents or teachers. Additionally, perceptions of ADHD in the Marshall Islands are very similar to those in South Korea. That is, they view it as bad behavior caused by poor parenting (Heine, 2002). Likewise, a study in Thailand found that people often believed that symptoms of ADHD was caused by poor parenting (Sakboonyarat, 2018).

As such, in these cultures, parents and/or teachers may be 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 South Korea, combined with a culture which places blame on parents and educators, it is logical that rates of ADHD reported in South Korea would be lower when compared to other countries. However, in fact, lower rates of ADHD in South Korea may be the result of attitudes towards ADHD rather than actual lower rates (Hong, 2008).

Likewise, 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” (Sakboonyarat, 2018). 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).”

One focus of the present research is to examine attitudes 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 attitudes and perceptions of ADHD is to examine specific cultural factors of Thai culture and how they relate to ADHD.

Hypothesis

            The researcher hypothesized that level of knowledge of ADHD of a sample of Thais was lower than the level of knowledge of Westerners. The hypothesis is based on prior research which indicates that levels of awareness of ADHD is lower in non-Western countries–especially in developing countries. Previous research found that the range of correct responses on the KADDS (on knowledge of ADHD) in Western countries ranged from 47% to 62%, while the percentage of incorrect responses on misconceptions (note: regarding misconceptions, a lower number indicates a better score) ranged from 16% to 30%. Along the same factors, non-Western countries range from 15% to 45% and 15% to 33%, respectively (Sciutto & Feldhammer, 2005).  

Research Design

            The study determined the level of knowledge of ADHD in a sample of Thais living in Thailand. The study analyzed the percentage of correct responses on the KADDS.

Research Instrumentation

            The study comprised of two parts. Part 1 consisted of demographic details developed by the researcher. The questions focused on participants’ age, gender, education level, and their region of origin in Thailand. However, convenience sampling was utilized, so ultimately participants’ demographic information was neither used to include or exclude them from the study. Part 2 comprised of Knowledge of Attention Deficit Disorder Scale (KADDS) (Sciutto & Feldhammer, 2005).

The KADDS is a 39 items scale designed to measure one’s knowledge of ADHD in three areas–treatment of ADHD, symptoms and diagnosis of ADHD, and associated features (general information about the causes, overall nature of ADHD, and prognosis of the disorder). These subscales were developed by 40 upper-level clinical psychology doctoral students. Content of the subscales required at least 75% agreement amongst the doctoral students in order to be accepted. Each item may be answered true, false, or don’t know. Selecting “don’t know” helps differentiates lack of knowledge from misconceptions or inaccurate knowledge. In other words, incorrectly selecting “true” or “false” indicates inaccurate knowledge, while selecting “don’t know” indicates lack of knowledge. In developing the items for the KADDS, an effort was made to include only items that were well-documented and empirically supported (Sciutto & Feldhammer, 2005).

The KADDS was normed on both teachers and non-teachers, so it is appropriate for use for both teachers and non-teachers. Prior research has found that those with prior exposure to ADHD, regardless of being a teacher or non-teacher, scored higher on the KADDS (Sciutto & Feldhammer, 2000). While prior research has found that teachers in Thailand scored low on the KADDS, the current research will investigate knowledge of ADHD amongst Thais (non-teachers) (Muanprasart et al., 2014). The KADDS was translated from English into Thai for the current study. .

Research Participants

The sample consisted of Thais 18 to 75 years old. The participants were required to be Thai citizens and able to read and write in Thai. An effort was made to recruit participants from various backgrounds (such as different educational levels and socioeconomic statuses) and from different regions of Thailand. These participants were required to determine knowledge of ADHD in a sample of Thai adults. The participants were selected using convenience sampling. Ultimately, 614 research participants were recruited.

Participants were approached in public areas, such as malls, to complete the KADDS via paper form or sent the KADDS via email to complete via surveymonkey.com. One hundred forty-nine completed it via surveymonkey.com, while 465 completed it via paper form. Two hundred sixty (42.4%) of participants were male and 354 (57.6%) were female. Two hundred sixty-eight (43.6%) of participants were between 18 and 28 years old; 169 (27.6%) were 29 to 39 years old; 114 (18.5%) were 40 to 50 years old; 63 (10.3%) were 51 to 75 years old.

          Regarding highest educational levels completed by participants, 300 (48.8%) completed high school; 214 (34.8%) completed a bachelor’s degree; 77 (12.5%) completed middle school; 14 (2.3%) completed a graduate degree (Master’s Degree or PhD); 10 (1.6%) completed elementary school. Therefore, 527 (85.9%) of participants had at least a high school education. Participants were recruited primarily in Bangkok, Udon Thani, and Nong Khai. Bangkok in located in central Thailand, while Udon Thani and Nong Khai are in North-East Thailand.Regarding province of origin, 321 participants were from Bangkok and 293 were from outside of Bangkok.

Table 1

 Study 1 Demographics Summary

Questionnaire Translation

In employing measurement scales developed overseas for research in a host country, it is necessary that these scales be appropriately translated into the host country’s language in order to have both contextual and conceptual equivalence. The method of choice was the ‘forward and backward’ translation technique as recommended by a number of researchers (e.g., McDermott & Palchanes, 1992; John, Hirsch, Reiber, & Dworkin, 2006).

The study employed this technique in the translation of the KADDS. (a) the instrument was translated into Thai by a bilingual translator; (b) a second bilingual translator independently back-translated the instrument to its original English version from Thai; (c) the two versions (the original English and the English back-translated instrument) were compared by the researcher; and (d) a meeting between the researcher and the translators was held to resolve any disparities identified between the original and the back-translated English version. This was achieved by offering possible alternatives in translation from English to Thai of the disputed items in order to ensure conceptual equivalence of the English and Thai versions. The process ended when the panel of translators agreed that both the forward-translated and back-translated versions were the same in meaning and context.

Pretest

A pretest of the KADDS was conducted prior to the actual study in order to check for errors and for readability. The researcher distributed the questionnaire to the research participants. According to Julious (2005), a good rule of thumb for sample sizes of pretests is approximately 12 participants. Ultimately, 13 participants completed the pretest. After the 13 research participants completed the questionnaires, each participant was interviewed to determine if there were any misunderstandings or confusion regarding each item. Upon verifying that the translated version of the KADDS was free from errors and comprehension problems, the researcher proceeded to conduct the actual study.

Data Collection

          A total of 800 questionnaires were distributed, of which 643 were returned. After examining the questionnaires, 614 were determined useable in that items were not missing and were legible. Therefore, 614 Thai participants were recruited to complete the KADDS. All participants were at least 18 years old and had at least one school-aged child. Out of the 614 research participants, 149 participants completed the KADDS via surveymonkey.com, while 465 completed it in paper form.

Data Analysis

            Once the data was collected, the frequency and percentages of correct responses were compared with the Western population. The existing range from published research were used for comparison. The researcher compared the existing range from previous research on knowledge of ADHD amongst teachers in Western countries, although the sample of the current study consisted of Thais (non-teachers). Although it may be argued that teachers would have higher knowledge of ADHD, previous research has found that knowledge of ADHD can be low amongst teachers, as well. Further, perceived knowledge of ADHD is often higher amongst teachers than actual knowledge. In addition, research has found that one in five teachers feel fairly or very uninformed about ADHD (Youssef, Hutchinson, & Youssef, 2015). In light of research that indicates that knowledge of ADHD amongst teachers may not necessarily be high, , the research has chosen compare the current study’s sample (Thai who are not teachers) to Western teachers.

The frequencies of participants’ responses on the KADDS were analyzed to determine the percentage of correct responses. The percentage of correct responses were compared to the percentage of correct responses on the KADDS in other research in different countries that appeared in prior research. Percentages of correct responses, incorrect responses, and “don’t know” responses were analyzed. In addition, the three factors measured by the KADDS, which includes associated features of ADHD, treatment of ADHD, and symptoms/diagnosis of ADHD were analyzed to determine correct responses of on each factor.

Results

          43.59% of the questions on the KADDS were answered correctly by the 614 Thai participants in the present research. 35.90% were answered incorrectly, while 20.51% of the questions were answered as “don’t know.” There are three possible answers to each of the 39 questions on the KADDS—true, false, and don’t know.

          Three factors are measured on the KADDS in regards to ADHD. These are as follows: Associated Feature of ADHD (15 items), Treatment for ADHD (12 items), and Symptoms/Diagnosis of ADHD (9 items). Three items on the KADDS have not yet been classified in any of the factors above. 33.3% of questions concerning treatment were answered correctly, 40% were answered correctly on associated features of ADHD, and 77.78% were answered correctly on symptoms/diagnosis.

          The present research indicates that this sample of Thais scored lower on the KADDS when compared to nationalities of Western countries. For example, previous research using the KADDS found that a sample in the Czech Republic answered 57% correctly; Germany, 54% correctly; Greece, 47% correctly; South Africa, 52% correctly; United States, 62% correctly (Sciutto et al., 2016). However, using the chi square test to determine if the difference were significant, it was revealed that the difference in scores were not statistically significant.

          However, the present research found that Thais scored higher on the KADDS when compared to previous research in other Asian countries and some Middle Eastern countries. For example, a sample of teachers in Vietnam answered 33% of the KADDS correctly; South Korea, 39% correctly; Saudi Arabia, 15% correctly. Although a sample in Iraq scored higher at 45%, it was nearly identical to the Thai sample on the present research which scored 43.59%. Using the chi square to test the differences in scores between Thailand and other countries, it was revealed that only the differences in scores between the Saudi Arabia and Vietnam were significant compared to the Thai sample. However, the samples are not easily comparable, as the Indian sample used a different instrument besides the KADDS to determine knowledge of ADHD (Sciutto et al., 2016).

Table 2

Chi Square Analysis Results

          Common misconceptions about ADHD found in the Thai sample (as indicated by 50% or more of the sample answering incorrectly on the KADDS) included the following: Misconceptions about the prevalence of ADHD in adolescents; misconceptions about youth with ADHD performing better in novel situations (which was a common misconception in other countries as indicated by over 50% of participants in previous research in the Czech Republic, Germany, Greece, Iraq, South Korea, South Africa, and the U.S. responding incorrectly); misconceptions about differing rates of ADHD across males and females; misconceptions of symptoms of ADHD in children under 4 years old; misconceptions about the effectiveness of behavioral and psychological treatments for ADHD (over 50% in Greece and Iraq responded incorrectly); misconceptions about the use of medications for ADHD. Furthermore, a common misconception in Greece and Iraq that medications for ADHD lead to addiction to drugs and alcohol was not found to be a common misconception in Thailand (Sciutto et al., 2016).

          The following were areas in which there were common misconceptions and/or lack of knowledge (combined) in the Thai sample as indicated by a combined percentage of 50% or more of responses being incorrect or responded to as “don’t know” on the KADDS: Lack of knowledge and misconceptions that ADHD medications lead to addiction; lack of knowledge and misconceptions that sugar leads to symptoms of ADHD; lack of knowledge and misconceptions that doctors can readily identify physical features that lead to a ADHD diagnosis; lack of knowledge and misconceptions about side effects of medications used to treat ADHD; lack of knowledge and misconceptions that children with ADHD are inflexible and adhere to rigid routines. Seemingly, the misunderstanding that children with ADHD are inflexible and adhere to rigid routines may point towards a lack of understanding of the differences between ADHD and autistic spectrum disorder. The researcher in unaware of prior research in other countries that reported combined percentages on misconceptions and lack of knowledge; therefore, the present research in unable to compare the current study’s results to prior research.

          The current research found common misconceptions in the Thai sample that were similar to Western countries and some that were not similar to Western countries. For example, misconceptions about youth with ADHD performing better in novel situations were common in several Western countries and Thailand. Likewise, misconceptions about the effectiveness of behavioral and psychological treatments for ADHD was a common misconception in Thailand and one Western country. Misconceptions that were not similar to the Western included the following: Misconceptions about the prevalence of ADHD in adolescents; misconceptions about differing rates of ADHD across males and females; misconceptions of symptoms of ADHD in children under 4 years old; misconceptions about the use of medications for ADHD.

Discussion of Findings

            The primary purpose of the study was to determine the level of knowledge and awareness of ADHD amongst a sample of Thai-speaking Thai parents with school-aged children. There is limited research on the level of knowledge of ADHD in Thailand, although a previous study, which focused on public school teachers in Thailand, found that their knowledge of ADHD was insufficient in that only 19% of teachers scored 70% or higher correct on the KADDS (Muanprasart et al., 2014).

            Although one may expect teachers to have a higher knowledge of ADHD than the general public, other research has found that only one in five teachers feel that they are fairly well or very well informed about ADHD (Youssef, Hitchinson, & Youseff, 2015). In addition, research has found that knowledge of ADHD is often low in people one would expect to have good knowledge of the disorder. For example, one study found that only 17% of medical students recognized all associated feature of ADHD (Qashqari, Alsaulami, Kama, & Mohammed, 2017).  As this research points out, profession or educational level does not necessarily equate to higher level knowledge of ADHD. To this researcher’s knowledge, there had been no prior research on the knowledge of ADHD amongst Thai parents or parents in Western countries. In light of prior research on knowledge of ADHD, the researcher determined that it was acceptable to compare knowledge of ADHD amongst Thai parents to knowledge of ADHD amongst Thai teachers in the Western population. Six hundred fourteen Thais were recruited mostly from Bangkok and North-Eastern Thailand.

          The study indicated that although Thais scored lower on the KADDS, the difference was not statistically significant; thus, it cannot be determined that the of level of knowledge of ADHD in Thailand is lower when compared to the level of knowledge of ADHD in Western countries revealed in earlier studies. In addition, Thais scored higher on the KADDS when compared to South Korea, Vietnam, and Saudi Arabia; however, the difference in scores were only significant regarding Vietnam and Saudi Arabia. Therefore, it cannot be determined that the level of knowledge of ADHD was statistically different from South Korea, but it can be determined that the level of knowledge of ADHD amongst Thais is greater when compared to Vietnam and Saudi Arabia.

          Nevertheless, given that only 44% of the KADDS was answered correctly in amongst the Thai sample, the current study concludes that an effort should be made to improve the level of knowledge of ADHD amongst Thais. Furthermore, certain cultural factors may result in less knowledge of ADHD and misunderstandings. Likewise, limited knowledge may lead to negative perceptions due to ignorance of the disorder.

            Knowledge of ADHD in Thailand was not lower when compared to previous research on knowledge of ADHD in Western countries. The differences in scores between the Thailand and Western countries was not significant. However, Thais had more knowledge when compared to samples from Vietnam and Saudi Arabia, as indicated by scores that were higher on the KADDS and statistically significant. 43.59% of the questions on the KADDS were answered correctly by the 614 Thai participants in the present research. 35.90% were answered incorrectly, while 20.51% of the questions were answered as “don’t know.”

            Three factors are measured on the KADDS in regards to ADHD. These are as follows: Associated Feature of ADHD (15 items), Treatment for ADHD (12 items), and Symptoms/Diagnosis of ADHD (9 items). Three items on the KADDS have not yet been classified in any of the factors above.

            Amongst the sample of Thais in the present study, 33.3% of questions concerning treatment were answered correctly, 40% were answered correctly on associated features of ADHD, and 77.78% were answered correctly on symptoms/diagnosis. The results of this study do not confirm research findings in other developing countries, in that knowledge of ADHD is usually lower in developing countries than in developed countries. This is also not in line with prior research that points out that people in Thailand have less accurate knowledge of mental disorders compared to Western countries (Kaewprom, Curtis, & Deane, 2011). Nevertheless, only approximately 44% of the KADDS was answered correctly which still indicates a need to knowledge of ADHD in Thailand.

            It is important to increase the knowledge of ADHD in Thailand, in order to ensure that those affected by ADHD receive appropriate support and treatment for it. As discussed in Chapter II, untreated ADHD can lead to many negative consequences, such as school failure, substance abuse, criminality, unemployment, and familial conflict, which can be detrimental to individuals and families, as well as costly to society in general. At the very least, untreated ADHD leads to underachievement and unfulfilled potential.

            Although rates of ADHD in Thailand are reportedly low, a lack of knowledge of ADHD most likely contributes to these low rates. In addition to low levels of knowledge of ADHD, cultural factors in Thailand may lead to low diagnostic rates and treatment-seeking behavior. For example, in cultures in which there are negative attitudes and perceptions of ADHD, there are reportedly lower diagnostic and less treatment-seeking behaviors, as well (Mueller, Fuermaier, Koerts, & Tucha, 2012). Further to this point, study 3 examined Thai cultural factors that may affect perceptions and attitudes towards ADHD (discussed under the study 3 subheading).

Conclusion

            The current study identified a need to increase knowledge of ADHD in Thailand in that knowledge of ADHD was low (only 44% of KADDS answered correctly). In addition, it found that cultural factors prevalent in Thailand were associated with negative attitudes and perceptions of ADHD.  However, Thais who had previous exposure to ADHD had less negative attitudes and perceptions of ADHD, indicating that knowledge of the disorder would mitigate the stigma associated with it. This further highlights the need to increase knowledge of ADHD in Thailand.

            Lastly, the current study opens up opportunities for future research. Future research should focus on improving awareness of ADHD in Thailand and reducing stigma towards the disorder. In so doing, the current research along with future research broadens the base of knowledge of ADHD in Thailand in hopes of improving access for treatment of ADHD; thus, improving the lives of children, teens, and adults with ADHD.

References

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