Attention deficit hyperactivity disorder (ADHD)

Cultural perceptions of child behaviour and ADHD treatment are likely factors that contribute to the underestimation of Asian children with ADHD and the underutilisation of ADHD treatment (Cuffe et al, 2005).

• Cultural differences in parental expectations about children’s behaviour, in parental coping strategies, and in their beliefs about the causes and treatment of disruptive symptoms are likely to contribute to inequalities in diagnosis and treatment of ADHD among Asian families (Garland et al., 2005). In determining whether a child has a mental health disorder, such as ADHD, Asian groups may use different criteria from those used by non-Asian families (Dinh & Nguyen, 2006). Additionally, traditional Asian perspectives concentrate less on psychopathology and more on enlightenment and ideal mental health (Lau & Takeuchi, 2001). For example, lower rates of ADHD diagnosis in East Asian countries may be attributed in part to a background of Confucianism (Moon, 2012; Young, 2012). Chinese, Korean and other East Asian societies value highly education, harmony with others, and respect for parents and elders. This cultural environment of high parental expectations and clear direction about expected behaviours may contribute to different rates of reporting the symptoms of ADHD (Moon, 2012).
• Cultural values influence parental attitudes, leading to different thresholds regarding how they view and tolerate children’s behaviour problems (Eiraldi et al, 2006). This also will in part determine how likely it is that parents are to seek help through clinical intervention for their children and for what purpose. For example, although Asian parenting styles tend to be more directive than that of non-Asian families, a relaxed parenting style is used with children younger than 6 or 7 years of age (Jose et al., 2000). Therefore, an underrepresentation of Asian families receiving mental health or psychiatric services may be partially due to Asian tolerance of a wider range of preschool behaviour than in non-Asian families. Asian parents may have different standards for what is considered a severe impairment and behaviour problem, than other parents (Norvilitis & Fang, 2005). Moreover, because symptoms of ADHD occur before age of 7, many Asian parents might not be aware of or report concerns with their child’s behaviour during that age range.
• The typical childhood behaviour problems thought to be of clinical concern in Western culture might not be perceived as severe by many Asian families. Asian parents often hold high expectations for their child’s behaviour, and they may be reticent about reporting children’s problems (Nguyen et al., 2004). For example, many Asian parents believe that personal effort and discipline are important factors leading to academic and personal success (Zadeh et al., 2008). Parents instil these beliefs early in childhood, so children are likely to compensate for behavioural difficulties by exerting effort and concentration in their schoolwork. This may be seen as a protective factor for most Asian families, as these qualities encourage family stability, structure, and an internal locus of control. However, childhood behavioural problems may not be acceptable to many Asian parents because such difficulties reflect on the whole family (Kramer, Kwong, Lee, & Chung, 2002). Thus, parents may not be willing to reveal or admit such personal matters to teachers and health professionals in order to avoid stigmatisation.
• When a child coming from a stable family does exhibit significant inattentive or hyperactive behaviours that lead to decline in academic achievement at school, parents are likely to become concerned since they place much emphasis on the child’s academic success (Sue & Sue, 2003). Parents see teachers as professionals with authority over schooling, but they may attribute their child’s negative behaviours to a teacher’s lack of classroom management, discipline, or instruction, especially if parents do not witness such behaviours at home.

When assessing and treating children from CALD groups, it is evident that extra precautions must be taken (Moon, 2012; Pierce & Reid, 2004; Young, 2012). Research shows that culture can directly affect both the assessment and treatment of ADHD (Pierce & Reid, 2004). This section provides an overview of the effects of cultural differences on the assessment and treatment of ADHD. Cultural difference may also have an impact on access to treatment and compliance with treatment programmes (Pierce & Reid, 2004; Young, 2012; Zhang et al., 2005). For example, children from CALD groups discontinue treatment before completion at a much higher rate than do Europeans (Bussing et al., 1998; Young, 2012.

Conners Behaviour Rating Scales (2008) and other child behaviour scales are used to examine whether a child exhibits challenging behaviour which falls outside the range of expected age-appropriate behaviour. Such behavioural concerns may include difficulties around hyperactivity, impulsivity, aggression, sustaining attention and/or disruptions to peer relations or learning.

Behavioural assessments involve a detailed process. To help formulate an accurate diagnosis they typically require parent interviews to attain a developmental history, coupled with diagnostic questionnaires, teacher interviews and/or school observations and a clinical session with the child. With this knowledge, children and parents can start to better understand the underlying causes of challenging behaviour and formulate treatment plans to modify both the behaviour itself and its impact on everyday life.

Cultural Considerations and Implications

• Two main issues arise when children from CALD groups are assessed for ADHD:
  • There is the possibility of rater bias. (Note that the term bias is used in the measurement sense and refers to systematic error which can over or under estimate true scores). Sonuga-Barke et al. (1993), describe two ways rater bias can affect assessment: (1) individuals from CALD groups conducting assessments may have different understandings of what constitutes disorder or may use different criteria to diagnose the same disorder, and (2) the same individual may diagnose people from CALD groups differently even when they present the same type of symptoms in equal severity.
  • The second issue that arises concerns normative use of behaviour rating scales in the assessment process. Behaviour rating scales were developed without consideration of cultural differences (Bauermeister et al. 1990). As a result, there are concerns pertaining to their normative use with CALD groups. Groups from CALD backgrounds are not adequately represented in the norm groups of many of the available behaviour rating scales (Reid, 1995).

• Clinicians must be aware of possible cultural differences in tolerance for ADHD-related behaviours and make sure that they obtain assessment data from multiple sources (parents, teachers and test administrators), to provide a comprehensive view of a child’s symptoms (Theilking & Terjesen, 2017).
• Another concern arises when non–English speaking parents are asked to complete behaviour rating scales. Clinicians need to know how to use interpreters effectively (see CALD 4: Working with interpreters). Some rating scales are now translated. For example, the ADHD Rating Scale IV is translated into Arabic https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841457/ (Hassan et al., 2009).

Behavioural interventions for ADHD

• Evidence-based behavioural interventions for ADHD, such as parent–child interaction therapy (PCIT), although structured and goal-oriented, require parents to adjust their form of parenting, their cultural values, and their communication with their child (Brinkmeyer & Eyberg, 2003). The goals of PCIT are to improve both parent–child attachment relationships and the behaviour management skills of the parent by establishing effective limit setting and consistency in discipline. This may create conflict with Asian parents who may feel that their own parenting skills are being criticised (Pham, 2013).
• The IYP programme has been shown to be an effective, strengths-based approach to improving parenting in Asian families, when it is culturally and linguistically tailored (Feng 2016). The Incredible Years Programme (IYP) is designed to help parents deal with their children’s difficult behaviours (Webster-Stratton, 2009). The aims of the IYP are to support parents to: increase the amount of praise for their children and reduce the use of criticism and negative commands; to set limits for children, replacing hitting and harsh discipline with non-violent discipline techniques; to increase the monitoring of children; to feel more confident about themselves and their parenting skills; to solve problems and communicate positively with their family; to gain their children's cooperation, leading to a more positive relationship with them.
• Parental expectations that are less consistent with the goals of the intervention also lead to low participation and retention rates. Asian parents expect concrete goals and strategies focused on solutions (Lau & Takeuchi, 2001). They frequently expect immediate results in their child’s behaviour. However, for children with ADHD, it may take at least several weeks or months for behaviour treatments or psychotropic medications to become effective in order to see an improvement in their behaviour.
• Working with parents directly on more concrete short-term behavioural goals will allow parents to see the immediate benefits of the intervention, and thus be more likely to continue with the intervention. Parents initially may be reluctant to share information about their own parenting styles and experiences. However, Asian parents can become empowered by sharing their parenting experiences where they have been effective or ineffective (Webster-Stratton, 2009). This is critical to successful parent engagement because it provides a context for treatment, engagement and planning. When parents are willing to share their goals of treatment, mental health professionals can determine what is important to them and adapt treatment plans based on these shared goals.

Pharmacotherapy

• Asian parents often do not comply with their medication regimen if they do not see immediate therapeutic effect or changes in their child’s behaviour (Nguyen et al., 2004). If parents are not informed about medication dosages and schedules or the purposes of the medication prescribed, they may discontinue treatment altogether.
• Prompt parents to ask questions.
• It is best to start low and go slow in prescribing medications and tailor medications for each child. There may be significant differences among some cultural groups in response to medication, such as their ability to metabolise or respond to psychotropic medications such as those used to treat ADHD (eg Ritalin) (Dawkins, 1996). Studies show that the cultural differences in clinical response to pharmacological medications may be a result of a higher prevalence of slow metabolisers in minority populations (Lawson, 1996). When CALD children are receiving pharmacological treatment for ADHD, it may be beneficial to closely monitor their behaviour and mental and physical health. Doing so may help catch any harmful side effects early so that adjustments can be made.

Cultural Considerations and Implications

• Cultural issues can have a significant impact on the treatment of ADHD (Livingston, 1999; Pham, 2013). Cultural matching of clients and therapists may improve treatment adherence and outcome (Rosenheck et al., 1995).
• Aim to get both parents to appointments as parents may have different child rearing views and parenting approaches.
• CALD parents may lack knowledge about ADHD (Pham, 2013). Different beliefs about ADHD and the need for treatment may affect treatment cooperation (ie following through with prescribed treatment interventions) (Lawson, 1996).
• Providing education to families of children from CALD groups about the nature of ADHD as a mental health disorder that is best treated by mental health clinicians, may improve treatment outcomes.
• The use of multimodal therapy (ie integrating pharmacotherapy with several educational or psychotherapeutic approaches) can maximise the chances of long-term adjustment (Richters et al., 1995).
• Providing psycho-education to parents and children may increase confidence in health professionals and increase the percentage of children who follow through the entire treatment cycle.
• Education for clinicians about cultural differences in child behaviours, parental styles and how to use interpreters in assessing ADHD is important. It may improve clinicians’ ability to recognise when a child from a CALD background needs treatment (Cuffe et al., 1995).
• Because research has demonstrated that CALD children and families discontinue treatment at a high rate, it is important for clinicians to develop motivational tools and educational programmes to increase adherence to treatment. For example, highlighting to parents that stimulant medications (eg Ritalin) have been shown to improve classroom behaviour and academic performance, improve interaction with teachers, friends and family and decrease anxiety (Goldman et al., 1998).

Psycho-education

• In order for parents to be more willing to participate in assessment and treatment for ADHD, one important goal is to mitigate the negative influences of shame and stigmatisation on help-seeking behaviour. Information on the prevalence of disruptive behaviour problems among school-age children might help to normalise parents’ experiences across acculturation levels and decrease stigmatisation.
• Psycho-education for parents and educational supports for their children to ensure academic and behavioural success at school can provide motivation to adhere to treatment which may improve outcomes and family engagement with mental health services.