Is ADHD different around the globe? The role of research cultures

An illness is an illness wherever you are. Perhaps this is true for organic diseases but the cultural background can play a tremendous role in the progression and even diagnosis of mental disorders (see e.g., David Dobbs recent post at Wired). However, what has been neglected is an appreciation of how culture affects the research underlying the diagnosis and treatment of psychological disorders. As a consequence, our view on the disorder can change.

Attention deficit hyperactivity disorder shows how culture can exert quite some effect on psychiatric research. In a 2007 meta-analysis by Polanczyk and colleagues prevalence rates were found to differ markedly between geographic regions, but not in the way you might expect. As opposed to the myth of ADHD as an American social construct, European and North American ADHD rates were not significantly different. But both were significantly different to the prevalence rates in Africa and the Middle East.
ADHD in school

One case of ADHD. Or perhaps two. Depends where we are.

However, Polanczyk and colleagues state that this is most likely due to different criteria for diagnosis and study inclusion. For example, while the diagnostic system published by the World Health Organisation is quite strict, the one published by the American Psychiatric Association is more liberal. Depending on which one the researchers adopt, the same person could be part of the ADHD group in one study and the control group in another one.
These different inclusion criteria appear to bias international comparisons. The severe restrictions on ADHD diagnosis in Middle Eastern studies can increase the apparent ADHD severity and social problems. Don’t be surprised then if you read that Middle Eastern ADHD kids fare worse in life than their American counterparts.
Beyond different inclusion criteria, the focus of studies can differ by geographic region. In a recent review, Hodgkins et al. (2012) showed that about half of North American and European ADHD studies sampled adults. East Asian researchers, on the other hand, were mainly interested in adolescents and only sampled adults in about a third of studies. Will this result in ADHD as a potentially life long disease in the Western view while the Easten perspective sees it as part of the transition to adulthood? If so, researchers could be partly to blame for this difference.
Finally, what life consequences a ADHD diagnosis entails is differently researched. While East Asians are mainly interested in effects on self-esteem, Europeans focus more on antisocial behaviour. North American researchers, on the other hand, measure drug abuse and addiction outcomes more than their European or East Asian counterparts. A single headline grabbing result could forever associate inattentive kids with drug abuse. Don’t expect this result to emerge in Asia, it is likely to be found in the US.
This is not to say that ADHD, its prevalence in different age groups or its life consequences are entirely determined by research agendas. Evidence is still needed to support diagnosis or treatment. However, whether anyone ever looked for this evidence is dependent on culture. Across the world research cultures, i.e. strategies to get scientific evidence, differ. Don’t be surprised then if evidence based psychiatry differs as well.

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Hodgkins P, Arnold LE, Shaw M, Caci H, Kahle J, Woods AG, & Young S (2011). A systematic review of global publication trends regarding long-term outcomes of ADHD. Frontiers in psychiatry / Frontiers Research Foundation, 2 PMID: 22279437

Polanczyk G, de Lima MS, Horta BL, Biederman J, & Rohde LA (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. The American journal of psychiatry, 164 (6), 942-8 PMID: 17541055
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ResearchBlogging.org
images:

1) By CDC (http://www.cdc.gov/ncbddd/adhd/facts.html) [Public domain], via Wikimedia Commons

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If you were not entirely indifferent to this post, please leave a comment.

2 comments

  1. Whether or not the social construction of reality is a myth (Kunert’s word), we certainly are not simple consumers of an objective reality which exists entirely independent of our social practices and engagement with the world. The universe of diseases appears to allopathic doctors as objective given the practices they use just as the universe of problems and issues appears to shamans as objective given the practices that they use in their engagement with the world. But that said, we ought to be somewhat surprised if allopathic (Western trained ) doctors in Europe and America and Asia were making sense of behavior-as-symptoms in radically different ways such that the construction of ADD by doctors in London would be incredibly different from the way that doctors in Chicago or Cairo… Less surprising would be how those diagnosed might fare in different cultures….

    1. Thanks a lot Bernard. Interesting comment.

      There certainly is no indication that I am aware of that ADHD is an American social construct. However, I have come across this claim and checked it in the review by Polanczyk and colleagues. Turns out that, if you look carefully you can find ADHD sufferers all over the world. Please view my comment of the ‘myth of ADHD as an American social construct’ in this context.

      Otherwise, I am afraid I cannot fully follow your comment. But from what I get, it appears worthwhile to remind ourselves that this post is not about cultural differences in medical practice. It is about different practices in ADHD research. So, if you find it less surprising that there are cultural differences in how ADHD sufferers fare, I would say that it is very difficult to assess whether this cultural difference is actually real. Comparing studies from different countries with each other does not work because of differences in diagnoses and outcomes of interest. Only dedicated international studies could do the job properly. I am not aware of any such study in the context of ADHD. If you know of one, I would be interested to read it.

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