ReviewAttention-Deficit/Hyperactivity Disorder in a Diverse Culture: Do Research and Clinical Findings Support the Notion of a Cultural Construct for the Disorder?
Section snippets
Review Strategy
To accomplish this task, we proceeded a systematic computer review of the literature using four data bases: PubMed, PsycINFO, Scielo (Scientific Library on Line) and Lilacs (Latin American Literature on Health Science). References were searched using the following words: (Attention-Deficit/Hyperactivity Disorder or Attention-Deficit or Hyperkinetic Disorder or inattention or hyperactivity) and (Brazil or Brazilian). Only papers presenting research or relevant clinical findings on ADHD
Prevalence
We were able to find only 7 studies reporting prevalence rates of ADHD/HD in Brazil (Barbosa 1995; Cury and Golfeto 2003; Fleitlich-Bilyk 2002; Guardiola et al 2000; Poeta et al in press; Rohde et al 1999a; Vasconcelos et al 2003). All of these papers assessed ADHD in nonreferred samples (including studies not representative of the population assessed) and 4 of them (57%) used either DSM or ICD criteria (see Table 1).
As extensively reported in the international literature (see Faraone et al 2003
ADHD Construct
Few Brazilian investigations assessed the structure of ADHD symptomatology in nonreferred representative populations (Brito et al 1995; Moura 2002; Rasmussen et al 2002; Rohde et al 2001).
Brito et al (1995) assessed a sample of 2,082 children (mean age 11.2 years) from a public school using a 14-item teacher rating scale based on the DSM-III-R diagnostic criteria for ADHD. Two factors, Hyperactivity-Impulsivity and Inattention, were extracted from the data, and the factor structure was stable.
Comorbidity
Several investigations with referred and nonreferred samples, especially in the United States, have demonstrated that ADHD is a highly comorbid disorder (Angold et al 1999).
Some investigations in Brazil assessed the issue of ADHD comorbidity. Rohde et al (1999a) documented a high rate of comorbidity with Disruptive Behavior Disorder (47.8%) in a school sample of young adolescents, similar to those found in samples in the United States. Smokers were also overrepresented in the ADHD group than in
Family and Molecular Genetics Data
ADHD is a complex heterogeneous behavior disorder with a strong role for genetic factors in its etiology (Smalley et al 1997). Family studies in the United States documented that about one quarter of children presenting ADHD will have an ADHD parent (Faraone 1997). Consistent with these findings, Roman et al (2001) documented a high parental ADHD diagnosis in Brazilian probands (31% full diagnosis; 39% including subthreshold cases).
The mode of ADHD transmission is unclear, but it is likely to
Data on Impairment
Studies in the United States have consistently documented a huge variety of impairments associated with the disorder. For instance, the rate of grade retention was significantly higher in ADHD subjects than in non-ADHD controls, especially in the subgroup with ADHD and impaired executive functions (see Biederman et al 2004). In the only study addressing school impairments associated with ADHD in Brazil, we found that the proportion of ADHD adolescents with more than one grade repetition (87%)
Treatment Findings
Several studies clearly documented the efficacy of stimulant medication in reducing core symptoms of ADHD in school age children from developed countries, as well as improving function in a number of domains (see, for example: MTA 1999).
In the only clinical trial conducted in Brazilian ADHD children and adolescents, the group that received methylphenidate had a significantly greater decrease in Abbreviated Conners Rating Scale (ABRS) scores and a significantly higher increase in CGAS scores
Conclusions
It is well-established that there are significant differences in the demands of environment (e.g., at home and at school) according to cultural aspects. Also, the expectation and tolerance for certain behaviors vary in different cultural groups (Livingston 1999). Thus, standards for normal and deviant behaviors are culturally determined (Reid 1995). Although criteria for ADHD are operationally defined in both the DSM and the ICD, some degree of subjectivity remains. The request that symptoms
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