Elsevier

Biological Psychiatry

Volume 57, Issue 11, 1 June 2005, Pages 1436-1441
Biological Psychiatry

Review
Attention-Deficit/Hyperactivity Disorder in a Diverse Culture: Do Research and Clinical Findings Support the Notion of a Cultural Construct for the Disorder?

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There is still some debate in the literature whether Attention-Deficit Disorder/Hyperactivity (ADHD) is best conceptualized as a biological disorder or if it is best understood as a cultural construct. This review aims to contribute to disentangle this issue assessing clinical and research data on ADHD in a complete diverse culture from a developing country. We performed a systematic computerized review of the literature on ADHD in Brazil. All investigations were included if dealing with ADHD prevalence, etiology, symptomatological construct, or treatment. Findings were compared to those from studies in developed countries. The prevalence rates of ADHD (5.8% using DSM-IV criteria, 1.5% using ICD-10), the bi-dimensional factor construct extracted from factor analyses (inattention and hyperactivity/impulsivity), the pattern of ADHD comorbidity in clinical samples, the family genetic data suggesting a 39% family transmission in clinical samples and the role of some potential candidate genes in dopaminergic and noradrenergic systems, as well as data on the efficacy of methylphenidate in the disorder are all very similar to findings from developed countries. Taken together, these findings suggest that ADHD is not a cultural construct, reinforcing the importance of applying similar research methodology in different cultures to make findings comparable.

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

References (53)

  • J.J. Hudziak et al.

    A twin study of inattentive, aggressive, and anxious/depressed behaviors

    J Am Acad Child Adolesc Psychiatry

    (2000)
  • R. Livingston

    Cultural issues in diagnosis and treatment of ADHD

    J Am Acad Child Adolesc Psychiatry

    (1999)
  • L.A. Rohde

    ADHD in BrazilThe DSM-IV criteria in a culturally different population

    J Am Acad Child Adolesc Psychiatry

    (2002)
  • L.A. Rohde et al.

    Factor and Latent Class Analysis of DSM-IV ADHD Symptoms in a school sample of Brazilian adolescents

    J Am Acad Child Adolesc Psychiatry

    (2001)
  • L.A. Rohde et al.

    ADHD in a school sample of Brazilian adolescentsa study of prevalence, comorbid conditions and impairments

    J Am Acad Child Adolesc Psychiatry

    (1999)
  • J.M. Swanson et al.

    Dopamine genes and ADHD

    Neurosci Biobehav Rev

    (2000)
  • B.G. Winsberg et al.

    Association of the dopamine transporter gene (DAT1) with poor methylphenidate response

    J Am Acad Child Adolesc Psychiatry

    (1999)
  • A. Angold et al.

    Comorbidity

    J Child Psychol Psychiatry

    (1999)
  • G. Barbosa

    Transtornos Hipercinéticos

    Infanto

    (1995)
  • J. Biederman et al.

    Impact of executive function deficits and attention-deficit/hyperactivity disorder (ADHD) on academic outcomes in children

    J Consult Clin Psychol

    (2004)
  • H.R. Bird

    The diagnostic classification, epidemiology and cross-cultural validity of ADHD

  • G.N. Brito et al.

    Behavioral and neuropsychological correlates of hyperactivity and inattention in Brazilian school children

    Dev Med Child Neurol

    (1999)
  • G.N. Brito et al.

    A behavioral assessment scale for attention deficit disorder in Brazilian children based on DSM-IIIR criteria

    J Abnorm Child Psychol

    (1995)
  • F.X. Castellanos et al.

    Neuroscience of attention-deficit/hyperactivity disorderthe search for endophenotypes

    Nat Rev Neurosci

    (2002)
  • C.R. Cury et al.

    Strengths and difficulties questionnaire (SDQ)a study of school children in Ribeirão Preto

    Rev Bras Psiquiatr

    (2003)
  • S.V. Faraone

    Familial transmission of Attention-Deficit/Hyperactivity Disorder and comorbidities

    (1997)
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