Attention Magazine February 2018

Children and Teens in Southeast Asia Have ADHD, Too

By Roby Marcou, MD

FOR THE PAST TWENTY-FOUR YEARS I worked as a developmental behavioral pediatrician throughout Asia, based out of Indonesia and then Singapore. My patient population included children and teens from every corner of the world–children attending local schools in Indonesia, Singapore, the Philippines, or Vietnam, as well as those attending international schools throughout the region. These patients were either citizens of the country they were living in, long-term residents, or more transient expatriates. Many had early exposure to multiple cultures, languages, or school systems. They sometimes came from countries where the understanding of ADHD is different than in the United States. All these factors contributed to the process of understanding and managing their attention difficulties.

A wide range of cultural factors contributes to differences in the diagnosis of ADHD among countries. While I adopted a US gold-standard approach to evaluating patients, of course I remained mindful of the important cultural, social, educational, and diagnostic differences among the patients I saw:

• Different diagnostic thresholds and categories. In most countries, the ADHD diagnosis is now aligned with similar diagnostic criterion and approaches as in the US. However, in countries such as the United Kingdom, the overall reported incidence of ADHD is somewhat lower than in the US. Some countries have maintained a diagnostic understanding of ADHD which requires the presence of hyperactivity or impulsivity. The inattentive presentation of ADHD would be diagnosed as low working memory or learning differences. Cultural understandings of the behavior and attention variations of those with ADHD sometimes are associated with country-specific diagnoses. My patients might come to me with diagnoses such as “pathological demand avoidance,” for example.

• Different expectations. Cultural expectations and lifestyle definitely impact how ADHD symptoms are described. The expectations a Singaporean parent might have for a daughter, in terms of attention and activity, might be very different than what an Argentinean parent might have for a son. In part, ADHD is diagnosed based on the reporting of parents and teachers. That reporting is impacted by their own expectations or perceptions of what is normal, often based on cultural considerations. The criterion for ADHD, however, are basically the same for all children and adolescents of any gender and any age.

• Sleep and exercise. Sleep expectations vary from country to country as do opportunities for physical exercise. These are not factors that cause ADHD, but they do affect how significant the patterns might appear. Access to technology at bedtime and throughout the day is the norm for even young children in some cultures, and further compromises sleep and exercise.

• Classroom environment. Large classrooms with 35-40 students made it difficult to detect children with primarily the inattentive presentation of ADHD. In situations like this, a child who is quietly inattentive is not seen as a problem, and so a teacher might not identify concerns. In Singapore, which is on the Equator and very warm all year round, most public school classrooms did not have air conditioning. Large and noisy ceiling fans as well as windows opened to the noisy playgrounds were the norm in the classrooms. Such learning environments can obscure or amplify symptoms and often impact the way symptoms might be seen differently by parents and teachers.

• Academic expectations. Because of the culture of intensive tutorial work in much of Asia, children have less time for play, for physical activity, and sometimes for sleep. But they sometimes have stronger early academic skills. If academics are okay, there can often be less concern about the nature of attention issues. With intense expectations, however, there may be greater intolerance of the inconsistency often seen with ADHD.

• Family and social factors. One major difference for the families I worked with overseas was the availability of and in home. This was often a big stress reliever, as the level of practical support for daily living, especially the inevitable challenging moments, was high. It could also be a complication, however, as the household helper often took on a parenting role and cohesive behavioral management could be made more challenging.

In my experience, ADHD is basically diagnosed in a similar way worldwide. Rating scales are done, a complete history is taken, and a comprehensive assessment is performed to understand learning, attention, and behavior. As in the US, the diagnostic process might involve a psychologist, psychiatrist, or developmental pediatrician. Many countries have adopted national standards for how the diagnosis should be made, largely using this same model.

Sometimes, unfortunately, diagnosis is based on limited or incomplete information, as is sometimes true in the US. Parents often came to me skeptical of assessments that only involved rating scales or verbal reporting. Most parents want to understand their children thoroughly, not jump to a diagnosis or treatment. For parents, as well as schools, having thorough information about a child’s learning and behavior is key to effective management.

Parents from all the countries where I practiced wanted to consider a broad range of approaches to helping their child. Parents from some countries can draw upon considerable family or friend experience with ADHD medication, but in my office many parents wanted to try other treatments first. This was true regardless of culture, but often Asian parents were initially most skeptical.

For fourteen years, while I was working in Indonesia, I was not able to prescribe any medications due to licensure restrictions. This made it all the more important that the child or adolescent be thoroughly evaluated, so we could devise approaches to strengthen strengths, to target educational needs, to provide emotional support, to scaffold learning, and to create real understanding of the nature of the child. Even in Singapore, our formulary of medications for ADHD is extremely limited–only Ritalin, Concerta, or Strattera. So, medication, while useful and important, most certainly could not be the only approach for any child.

Despite these differences in diagnosis and treatment, in all cultures the goal has to be to thoroughly understand why a patient functions as they do and how to help them learn and thrive. Where we were, or where they came from, ultimately was much less significant than treating the patient as an individual.

Roby Marcou, MD, is a developmental and behavioral pediatrician who has provided care in Alaska, Texas, Indonesia, Singapore, and throughout Asia. In addition to founding a clinic in Singapore, she served as an adjunct professor there at the National University Hospital Child Development Unit. She was a part-time middle school teacher at the Jakarta International School for a number of years. In 2017, Dr. Marcou returned to the US and joined the Chesapeake ADHD Center, www.chesapeakeadd.com. She works with families, schools, therapists, and other healthcare providers in an integrated approach to care which focuses on accurate assessment, evidence-based interventions, and careful, individualized case management. Visit her website, www.drrobymarcou.com.

ADHD DIAGNOSIS ABROAD

Here are examples of national standards from the UK and Singapore for how ADHD diagnosis should be made:

www.nice.org.uk/guidance/cg72/evidence/full-guideline-pdf-241963165 www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg_medical/current/2014/adhd/ADHD%20CPG_Booklet.pdf