Cultural factors in the diagnosis and treatment of children and

adolescents

M Maldonado, K Pope, C Millhuff

CULTURAL FACTORS

In conceptualization of what is a disorder

In the “nature” of the disorder

In the etiology of the disturbance

In the necessary interventions or remedies to deal with the problem

What is a disorder?

Dysfunction, impairment in psychosocial functioning within a family/social/cultural framework

A few diagnoses are categorical (e.g. autism)

Many are “dimensional” e.g. depressive, anxiety, hyperactivity symptoms

What is a disorder?

Conceptualization of disorder depends on expectations of the child

What parents hope for their children

Social norms of “normalcy”

The more “dimensional” the condition the more dependent on social/cultural field

What is a disorder?

E.g. Shyness. When is there social phobia?

Expectations of child, particularly girls

Are girls expected to be quiet and shy or assertive and outspoken?

Is self-effacement valued as a virtue or is child expected to express herself?

Nature of disorder 2

Genetically determined condition

Biochemical imbalance, neurotransmitters

Dysregulation of brain functioning (e.g. in mood regulation, attention deficit, impulse inhibition, etc.)

The disorder is a “natural” condition

Nature of disorder 3

External influence model

Transgression of a taboo

Punishment for transgression or omission

Influence of external agents ( envy, negative desires, anger)

Parenting strategies, early experiences in life, negative life events

What is a disorder?

Most conditions are dependent on culture but some are mostly “culture-bound”

E.G. Susto, evil eye, “cansancio”, etc.

Possibly Anorexia Nervosa

Attention Deficit hyperactivity disorder?

Oppositional defiant disorder?

Social/cultural factors influence “prevalence” of a disorder

E.g. Different rates of Hyperactivity in different countries

Higher rates in the US than in other countries

More emphasis on inattentiveness vs. more emphasis on hyperactivity

Expectations of parents and schools?

Differences prevalence

ADHD Prevalence of 3-20% in US (CDC) vs. prevalence 2-4 % in the UK*

Other European countries 1% (#) (ICD 10 criteria)

In US Less frequent diagnosis in Afroamerican. (Less access to treatment)

*Prendergast et al, 1988 . McArdle et al, 1995

#Swanson et al, 1998

ADHD PREVALENCE

Syndromatic construction is robust

(continuous performance test, actometer)

Using similar instruments in diagnosis leads to more similar prevalence (China, Italy, Germany , Brazil, etc.)

Cultural variations in what is rated as hyperactivity

(Bird, 1999)

Factors in prevalence

Nature of lifestyle:

Many transitions through the day, expectations in school for “sitting down” and “producing work”

Vs rural societies, less complex schedule

Expectation that children (e.g. boys) will be noisy and active

Factors in prevalence

Stress during pregnancy?

Effects of day care setting and quality of day care?

Cultural expectations?

ADHD

Hypothesis of ancestral evolutionary advantage to impulsiveness, high level of energy, quick action and fearlessness /disinhibition

Hunting societies, high level of conflict, etc.

Selective advantage

Symptoms of disorder

Manifestations of distress vary according to culture

How is worry, anxiety manifested?

How is depression manifested?

Language of the cultural group, what is acceptable in the role of the patient

Social/cultural factors influence “prevalence” of a disorder

E.g bipolar disorder

Particularly in early childhood (preschool)

Rarely diagnosed in many countries

More frequently diagnosed in the USA

What is the nature of the disorder?

Having agreed that there is a condition or dysfunction… what is its nature?

Split between “biological models” and “external influence model”

In US increasingly interest in “brain dysfunction” model

Interventions : if external influence

Eliminate source of influence (cleansing, rituals, neutralization)

Magical or trascendental interventions

Protective devices

Cleansing strategies (baths, herbs, infusions, elimination of toxins, etc)

Conceptualization of disorder determines intervention

Biological models require biological interventions:

Medications

Strategies to regulate the brain (e.g. occupational therapy, biofeedback , vitamines, supplements, etc.)

Medications : ADHD

Increase of 500% in prescriptions of psychostimulants in US since 1991 (DEA)

Medicalization of the problem

Often used as the only treatment

What is the effect of the diagnosis and treatment on the child?

Medications

Posible mixture of overdiagnosis in some centers (and over use of medications) with under diagnosis and under treatment in many other settings.

Lack of information about the effects of both

Psychotropic medications

Acculturation and transculturation

“Healthy immigrant” phenomenon

Found for several medical and psychiatric conditions

With acculturation there may be some negative consequences

Acculturation

Measuring degree of acculturation in Latinos (Burnam et al. 1987)

Epidemiological Catchment Area study , of rates of psychopathology in US. Related to Latinos:

Less acculturated people, less prevalence of alcohol and drug abuse, phobia, antisocial personality

US-Mexico Border study of adolescents (Pumariega et al, 1992)

4000 adolescents, 11 to 18 years old

Rates of depression and distress (Panamerican

Youth Inventory and Center for Epidemiologic Studies Depressive Scale)

Rate of drug abuse was 4x higher in US born adolescents (21% vs 5%)

Higher levels of distress and suicidal ideation in US born teenagers.

Acculturation adolescents

Risk factors: More time watching television

Less time spent in family activities

Less involvement with friends

Less involvement in sports

U.California Irvine Mental Disorders in Primary Care (Escobar et al, 1998)

1500 adolescents several groups

Mexican and Central American born :

Lower levels of posttraumatic disorder, depression, panic disorder

Better levels of physical functioning

Higher rates of “somatization