Abstract
“Cultural neuroscience is an interdisciplinary field of research that investigates interrelations among culture, mind and the brain.”. It postulates in part that culturally based daily routines yield culturally patterned neural brain patterns and lay the pattern for the embodied construction of the self and identity. Other studies have found evidence for the prevalence of the diagnosis of disorders like AD/HD in some cultures and not in others. Implications for research on a possible link between culture, cultural neuroscience, OC/HD, diagnosis methods, illness perceptions and help seeking behavior are discussed.
Introduction
The DSM-IV-TR criteria for attention deficit hyperactivity disorder and international classification have ten criteria for hyperkinetic disorder. These criteria require that for six months or more a patient manifest six or more symptoms of hyperactivity-impulsivity or inattention inconsistent with development or that is maladaptive. Symptoms of hyperactivity-impulsivity include fidgeting with feet or hands, squirming, trouble waiting for a turn and excessive talking. Symptoms of inattention include having trouble sustaining attention in play and tasks, being forgetful and being easily distracted. These symptoms must be present in more than one setting and they must affect academic, social or job functions. Additionally, some symptoms must have been present before the age of seven.
These well defined criteria are applicable to any culture. There was a perception that AD HD is a greater problem to “Western” cultures however, studies show that there is a 5.3% worldwide pooled prevalence of AD HD. There is also an indication that the geographic variability between prevalence estimates can be explained by the methods of the studies. . There is a strong body of evidence from high income countries suggesting the disorder is a neurobiological syndrome with complex genetic factors that indicate there is a mean heritability just under 80%. . There is also evidence that social determinants significantly influence the AD HD symptomotology. In high income countries low parental socioeconomic status, low parental education levels severe early deprivation, institutional upbringing, prenatal stress and low birth weight are all considers contributing factors along with family conflict parental mental disorder, prenatal smoking and alcohol use. This could suggest that a cultural deviation determined by social class rather than by geopolitical location. Other studies suggest that in American culture, another factor that strongly affects the diagnosis and treatment of mental health disorders is the citizenship status of the children and their parents. Cultural differences, religious beliefs, or folk beliefs can affect the familial view regarding the cause and appropriate treatment for mental disorders. Even racial and ethnic minority families from the United States may have different expectations, attitudes and mores regarding mental health disorders, their diagnosis and treatment.
Discussion
There are culture bound syndromes such as Anthropophobia found in China, and characterized by a fear of being looked at. In the highly structured interdependent Eastern, culture of China where there is more emphasis placed upon maintaining social harmony individuals are more concerned with the possibility of offending others. As a result, some individuals manifest the symptoms of Anthropophobia, which are typically a ridged degree of conforming, extreme introversion and a collectivist orientation. This disorder is not specifically identified in Western psychopathology, which is far less interdependent and much less likely to foster such extreme concern with offending others.. On the other hand, Anorexia Nervosa is a primarily western phenomenon driven by an individualist culture, which emphasizes ego-focused emotions like feelings of superiority and pride. The motivations are diametrically opposed to Anthropophobia Anorexia Nervosa is an attempt to gain attention by being more attractive and “better” than others are. Disorders such as depression and AD HD, which are common to all cultures frequently, manifest differently in especially in light of the respective individualism or collectivism of a culture. When individuals from cultures are transplanted into circumstances where the familial standards are different from the mainstream culture additional complications arise. These cultural differences can play a role in the recognition of mental illness and the ability of a care provider to detect and diagnose it this increases the potential for misaligned treatment as well. . In the case of AD HD, research indicates that neuroimaging, neurochemical studies and neuropsychological genetics have indicated fronto-striatal network abnormalities as contributing to AD HD. The ability to use functional imaging studies on the most common world wide childhood mental disorder may lead to a greater understanding on how to approach cross cultural issues in the diagnosis and treatment of this disorder. To date Western medicine has been utilizing pharmacological solutions in the treatment of AD HD. However, several modalities that are more connected with Eastern culture have also proved their efficacy in the treatment of AD HD. Meditation and yoga have joined cognitive behavioral therapy to provide alternative treatments, which have a powerful effect upon the cognitive and emotion neural brain pathways. . Studies concerning specific ethnic groups such as Hispanic patients indicate that while they are less likely to be diagnosed than Caucasian patients are it is also indicated that they are undertreated. The cause of this is multi-faceted. One element to consider is that the designation “Hispanic” includes persons of Mexican, South American, Spanish Puerto Rican and Cuban decent, just to name a few. These individuals, while they share a similar language may have broadly different and significant cultural differences. Additionally, there is the likelihood that there are educational and socio-economic differences as well. Since it has been established that within a society the socio-economic class distinctions strongly affect the likely hood of manifestation of AD HD symptoms it must be factored into any cross cultural assumptions made about the occurrences of AD HD in the Hispanic communities as well. There are cross cultural influences that are consistent in the Hispanic community that influence treatment seeking patterns. One of these is personalismo, the ability to develop warm personal relationships and another is familismo, which is a loyal, reciprocal relationship with family. These factors can contribute, or detract from treatment acceptance and efficacy; if friends and family are involved treatment is more likely to be effective and treatment plans adhered to. On the other hand, if friends and family, including the extended family such as grandparents, are not educated about and engaged in the treatment process it is far less likely to be successful. .
The treatment of Haitian Americans raises a different set of concerns regarding AD HD. American treatment plans rely on a preference for pharmacological solutions which many Haitians and Haitian Americans view the psychoactive medications as leading to substance abuse and mental illnesses. Alternative psychosocial treatments, which include parent training, contingency management and behavior therapy along with cognitive behavioral treatment has not been as helpful as pharmacological solutions. In this situation, complementary and alternative medicine has appeal. Physicians can assist families in determining which treatments are likely to prove truly effective. In the Haitian culture the interpretation of typical AD HD behavior may be attributed to poor parenting, intentional bad behavior ore an “unnatural” condition that could be caused by bad spirits or as a punishment by God. Within the Haitian American culture the use of therapeutic foods, natural sedatives, natural purgatives, religious treatments and Western medicine may often be combined. .
AD HD is a condition that children suffer from world wide and persists into adulthood for 40% to 70% of these children. However, the interpretation of behavior and symptoms varies across cultures even though the signs and symptoms are consistent are basically the same the different countries and socioeconomic class of the parent effects how treatment may be administered. In studies conducted around the world, African American parents were more unsure of the potential causes and treatments of AD HD. In another school based study, white children with AD HD were twice as likely as African Americans to be diagnosed and treated; parental involvement was a factor in this study. A third study had the African American children were diagnosed at a higher rate. American school studies showed additional variances in cross cultural diagnoses of Hispanic, White and African American teachers no determination was made in these studies if the variations were due to ethnic differences, cross-cultural diagnostic measures, or bias in the rater’s assessments.
Cross cultural differences in the parental and medical care givers in different societies does not negate the existence of AD HD as a world wide childhood disorder that frequently persisting into adulthood. There is evidence that indicates that there are links between culture, cultural neuroscience, AD HD, diagnosis methods, illness perceptions and help seeking behavior depending on the patients’ cultural background and the parents’ social and economic class within the culture. Scientific research using that neuroimaging, neurochemical studies and neuropsychological genetics has indicated fronto-striatal network abnormalities as contributing to AD HD. Further studies are needed to research more consistent diagnoses of AD HD and treatment efficacy in cross cultural studies. It is to be hoped that as neuroimaging technology becomes more affordable additional studies will be conducted that will contribute to the body of knowledge on this disorder.
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