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Personality Disorders

By David Shahidi

Media and more specifically the movie industry has created a royally skewed picture of mental disorders. This skewed view becomes more evident when considering the group of mental disorders called personality disorders. Upon hearing the term personality disorder one starts to think of the many examples of movies that have made the antisocial personality disorder (or better known as Psychopathy) and multiple personality disorder (which by the way is not considered a personality disorder and is categorized as a dissociative disorder) their main story telling device. This example should be more than enough to show the distorted and unscientific view of personality disorders prevalent among the general public, exacerbated by the media’s portrayal of such disorders.

To have a better understanding of personality disorders it would be useful to first reference the DSM-5. According to the DSM-5 a personality disorder is a pattern of experience and behavior that differs greatly from what is culturally expected from an individual, it is enduring and inflexible and is pervasive and can cause distress or impairment (American Psychiatric Association, 2013, p. 645). What this means in layman terms is that a personality disorder is just like any other mental disorder in that it causes distress and impairment, but it differs from any other mental disorder in that it is stable over time meaning even when symptoms are treated, it is still there and the symptoms will resurface again. That is why the prevalent view is that these disorders are not treatable, but the symptoms can be dealt with (either through medication or therapy) and the daily life of the individual could become manageable. In a way it seems like the symptoms are a part of the individual’s personality, it is just the way they are, and that is why they are called personality disorders. The DSM-5 categorizes personality disorders as such: Avoidant Personality Disorder; Borderline Personality Disorder; Narcissistic Personality Disorder; Obsessive-Compulsive Personality Disorder; Schizotypal Personality Disorder; Antisocial Personality Disorder; Dependent Personality Disorder; Histrionic Personality Disorder; Schizoid Personality Disorder; and Paranoid Personality Disorder (American Psychiatric Association, 2013).

The global prevalence rate of personality disorders stands at about 6% of the world population (Tyrer et al., 2010). This prevalence doesn’t seem to show a systematic difference among different cultures, ethnicities and countries. Thailand, a south East Asian nation with the capital city of Bangkok, falls into the same prevalence brackets. In total, Asia seems to have the same prevalence rates when it comes to personality disorders, still there are some inconclusive evidence that the prevalence maybe lower than the global average (Bernier, Kim and Sen, 2014).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Bernier G.‐L., Kim Y.‐R., and Sen P. (2014), A systematic review of the global prevalence of personality disorders in adult Asian populations, Personality and Mental Health, 8, 264–275, doi: 10.1002/pmh.1270

Tyrer, P., Mulder, R., Crawford, M., Newton-howes, G., Simonsen, E., Ndetei, D., … Barrett, B. (2010). Personality disorder: a new global perspective. World Psychiatry, 9(1), 56–60.

The post Personality Disorders appeared first on Lighthouse Counseling Bangkok.

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Anxiety Disorders:

Generalized Anxiety Disorder (GAD)

By David Shahidi

It is natural and normal for people to feel worried and anxious sometimes. This rather unsavory sensation keeps one on their toes and generally more aware of what needs to be done to get through that feeling. Now try to imagine having that feeling of “worry” all day, every day. How life would be like? Can the individual live a “normal” life, or concentrate on a specific task, be it work or school, to accomplish it to the best of their abilities?

The answer to the above questions is a resounding “No”, and that is what separates normal everyday worriers from “pathological” worrying. This is where Anxiety Disorders come in, and that is why the diagnosis is available. Being worried always and in a disease like manner is not healthy and it certainly disrupts the daily life of the individual and impairs their normal functioning.

These individuals are sometimes informally called “worrywarts” because they just cannot stop worrying about things that may seem trivial to healthy individuals, things such as expecting a disaster in any situation, constant worrying about family members, friends, work, school. In more severe cases these worries extend to even the miniscule details of everyday life such as an appointment with a hairdresser, going out to buy groceries or folding laundry. These individuals seem restless and unsettled and may involuntarily cause negative reactions in others.

Several causes have been proposed for the generalized anxiety disorder, such as genetic factors, brain chemistry imbalance at the nerve endings connecting regions of the brain associated with emotion and thinking, and environmental factors such as traumatic experiences.

The official diagnosis criteria outlined in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are as follows:

“A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

  1. The individual finds it difficult to control the worry.
  2. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one item required in children.

  1. Restlessness, feeling keyed up or on edge.
  2. Being easily fatigued.
  3. Difficulty concentrating or mind going blank.
  4. Irritability.
  5. Muscle tension.
  6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
  7. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  8. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
  9. The disturbance is not better explained by another medical disorder.” (American Psychiatric Association, 2013).

The global average prevalence of anxiety disorders was at 7.3% with African cultures having the lowest prevalence at 5.3% and the Euro/Anglo cultures having the highest at 10.4% (Baxter et al., 2013). It has also been shown that anxiety disorders are more prevalent in women, especially Caucasian women in developed countries compared to their counterparts in developing countries. In comparison to those data points, in Thailand, a South East Asian nation, in the capital city of Bangkok the prevalence of anxiety disorders was at 1.4%, according to the Thai National Mental Health Survey 2013 (Sooksompong et al., 2016) which falls on the lower end of the spectrum.

Treatment considerations for Anxiety Disorders include medication (e.g. antidepressants and anxiolytics) and therapy. A combination of both is the preferred method to consider a bio-psychosocial model of the individual.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Baxter, A., Scott, K., Vos, T., & Whiteford, H. (2013). Global prevalence of anxiety disorders: A systematic review and meta-regression. Psychological Medicine, 43(5), 897-910. doi:10.1017/S003329171200147X

Sooksompong, S., Kwansanit, P., Supanya, S., Chutha, W., Kittirattanapaiboon, P., Udomittipong, D., Piboonarluk, W., & Saengsawang, S. (2016). The Thai National Mental Health Survey 2013: Prevalence of Mental Disorders in Megacities: Bangkok. Journal of the Psychiatric Association of Thailand, 61(1), 75-88. Retrieved from https://www.tci-thaijo.org/index.php/JPAT/article/view/54842

The post Anxiety Disorders appeared first on Lighthouse Counseling Bangkok.

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Mood Disorders

Major Depressive Disorder

By David Shahidi

During normal daily life, one experiences “good moods” and “bad moods”. Upon hearing a good news, like getting a job we love, we feel elated and are in a good mood for the rest of the day or maybe even for days to come. Similarly at the same time, hearing an unpleasant news, like the loss of a loved one, could put us in a bad mood for the rest of day or even for days to come. The experience of these normal emotions should not be confused with a mood disorder. Professionally, the disorder designation is only used when the everyday emotional state of the individual is affected and that makes them unable to function normally and productively.

Imagine a scenario in which an individual loses someone s/he loves. We can all agree that feeling sad and grieving for a period of time seems “normal”, but the person should still be able to care of themselves and their everyday affairs, and they usually come to terms with the loss and move one with their daily lives. In this scenario, if the individual in unable to move on and the feelings are sadness are with them 24 hours a day and seven days a week, then they would not be able to take care of themselves or go to work or study. In other words their daily routine is interrupted and that makes then unable to adapt to normal daily life challenges.

Our imaginary scenario just described a mood disorder, namely major depressive disorder. The distinction between “just feeling sad” and the “clinical depression” (as it is commonly called) should be clear now. In fact the word depression and its derivatives are so commonly used to refer to the normal and usual experience of sadness and general low mood that a new term had to be used to distinguish the “real” pathology (disorder) cases. That is how the “clinical depression” came to be used.

The official diagnosis criteria outlined in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are as follows:

“1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

  1. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)
  2. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
  3. Insomnia or hypersomnia nearly every day.
  4. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  5. Fatigue or loss of energy nearly every day.
  6. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  7. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  8. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide” (American Psychiatric Association, 2013).

According to the DSM-5 to be diagnosed with major depressive disorder 5 (or more) of these symptoms should be present in a 2 week period and should be a sign of a major change from previous functioning patterns.

In other words, major depressive disorder, generally has 2 distinct sets of symptoms, namely the emotional or affective symptoms and the physical or somatic symptoms. Examples of affective symptoms include experiencing generally sad mood for extended periods of time (more than 2 weeks), loss of interest in activities previously enjoyed, feelings of hopelessness and helplessness, low self-esteem and slow self-worth. Examples of somatic symptoms include the afflicted individual feels fatigued and has low energy to cope with daily life demands, experiencing sleep problems, chronic pain usually in the form of headaches, feeling heavy in the chest area, and digestive problems.

Depression is a common affliction across the world, with its lifetime prevalence being in the 10% range, “with higher prevalence in women (14.4%) and in countries with a medium human development index (HDI) (29.2%)” (Lim et al., 2018).

It is interesting to note that representation of depressive symptoms is different across the world, with the more developed, western countries showing the more affective symptoms and the less developed, Asian countries showing more of the somatic symptoms.

As a point of comparison, in Thailand, a South East Asian country, according to the Thai National Mental Health Survey 2013, in the capital city of Bangkok, the prevalence of all mood disorders (major depressive disorder included) was at 0.4% (Sooksompong et al., 2016) which is considerably lower than the global average. The main explanation could be the expression of somatic representations of depression. People feeling depressed, express their situation in more somatic forms, such as experiencing headaches, feeling tired, having trouble breathing and general stomach problems. That is the reason that the individual will seek a physician for their complaints instead of consulting a mental health professional. The social stigma associated with mental health problems should also be noted as an important deterrent in seeking professional help.

Depression, in any form, should be dealt with and professional help should be sought as it can be life threatening in its more severe forms. Fortunately, depression is treatable and the treatments include therapy and medication.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Lim, G. Y., Tam, W. W., Lu, Y., Ho, C. S., Zhang, M. W., Ho, R. C. (2018). Prevalence of Depression in the Community from 30 Countries between 1994 and 2014. Scientific Reports, (8)1, 2045-2322. doi: 10.1038/s41598-018-21243-x

Sooksompong, S., Kwansanit, P., Supanya, S., Chutha, W., Kittirattanapaiboon, P., Udomittipong, D., Piboonarluk, W., & Saengsawang, S. (2016). The Thai National Mental Health Survey 2013: Prevalence of Mental Disorders in Megacities: Bangkok. Journal of the Psychiatric Association of Thailand, 61(1), 75-88. Retrieved from https://www.tci-thaijo.org/index.php/JPAT/article/view/54842

The post depressionthailand appeared first on Lighthouse Counseling Bangkok.

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The Seven Types of ADHD

Although the DSM-5 only recognizes three types of ADHD (as described above), Dr. Daniel Amen, a psychiatrist, researcher, and rexpert in ADHD who was written several books on the subject, puts forth an alternative concept of ADHD. According to Dr. Amen, he conceptualizes ADHD as have seven different subtypes. Due to the many complexities of ADHD, I believe it is worth taking time to look at Dr. Amen’s ideas, as it may help the reader understand how complicated it can be for laypeople to identify, as well as for clinicians to accurately diagnose ADHD. Indeed, these complexities contribute to controversy surrounding ADHD.

According to Dr. Amen, the seven types of ADHD are as follows:

  1. Classic ADHD

Classic ADHD is what people typically think of when they think of ADHD. Symptoms of this type of ADHD involve difficulty maintaining focus, impulsivity, hyperactive and impulsivity. This type of ADHD would be most close related to what the DSM-5 labels as ADHD, Combined Type.

  1. Inattentive ADHD

Symptoms of Inattentive ADHD “are short attention span, distractibility, disorganization, procrastination. People with this type are not hyperactive or impulsive. They can be introverted and daydream a lot (Amen, 2001).” This type of ADHD would most close resemble what the DSM-5 calls ADHD, Inattentive Type.

  1. Over-Focused ADHD

People with Over-Focused ADHD usually have the common stereotypical symptoms of ADHD, as well as a problem with being able to shifting attention. People with this type of ADHD tend to get stuck into negative thoughts and negative patterns and/or behaviors. In addition, they may have great difficulty to shifting thoughts and tasks, as well as having a tendency to be inflexible.

  1. Temporal Lobe ADHD

This [ADHD] type has core [ADHD] symptoms along with temporal lobe symptoms. The [temporal lobe]…is involved with memory, learning, mood stability, and visual processing of objects. People with this type have learning, memory, and behavioral problems, such as quick anger, aggression, and mild paranoia.

  1. Limbic ADHD

People with this type of ADHD tend to have high-levels of sadness and dysthymia. They also have chronic low self-esteem, low energy, feelings of guilt, and/or moodiness. Although aspects of this type of ADHD may resemble depression, Dr. Amen states that it is not depression..

  1. Ring of Fire ADHD

People with this type of ADHD “don’t have an underactive prefrontal cortex, as with Classic and Inattentive ADD.” In contrary, their brain tends to be overactive across all areas. Symptoms of this type of ADHD may include being sensitive to noise, light, and touch. They have epsiodes in which they display mean behavior. In addition, these people can be unpredictable, fearful, and anxious.

  1. Anxious ADHD

People with Anxious ADHD have all the standard symptoms of ADHD, but are also very anxious, tense, and may have physical symptoms, such as headaches and stomache aches. They may be overly negative, tend to imagine the worst case scenario in all situations, and may freeze an anxiety-provoking situations, most of all in social situations where they may be juedged by others.

These seven types of ADHD proposed by Dr. Amen, illustrate how difficult it may be to accurately identify ADHD.  Dr. Amen believes these complexities lead to an underdiagnosis of ADHD. Indeed, such complexities would further complicate the identification of ADHD in cultures in which ADHD may be poorly understood. I believe that this is the case with the identification of ADHD in Thailand which most likely leads to an underdiagnosis of ADHD in Thailand.

(Amen, 2001)

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ADHD and Culture

Culture is an extremely important part of every person’s life and nobody can completely escape its influence, whether one’s native culture or adopted culture. Indeed, culture is extremely powerful and shapes multiple aspects of society, as well as the individual. Although we feel ourselves unique (of course some cultures encourage this feeling more than others, such as individualistic cultures in comparison to collective cultures), we are inextricably tied to our culture and influenced by it in ways of which we may not even be conscious.

Although most people are aware of how culture may influence one’s taste in food and music, cultural influence goes far beyond this. In fact, culture shapes the way we think and even our perceptions of reality. A branch of psychology, known as cultural psychology or cross-cultural psychology is dedicated to studying how culture shapes our psychological processes and perceptions. One aspect of cultural psychology is the study of how culture affects mental health, as well as the influence culture has over our perceptions of mental health.

Cultural psychology, reveals how culture provides a framework or context which determines how mental disorders are expressed. Indeed, certain mental disorders may be more prevalent in certain cultures or even unique to a particular culture. That is, a mental disorder may exist within one culture only.

Mental disorders which tend to be unique to a particular culture are known as culture-bound syndromes. Hikikomori, koro, and anorexia nervosa are cited as examples of culture-bound syndromes. Hikikomori, which appears to be unique to Japanese culture, refers to a mental disorders in which the primary feature is extreme social withdrawal, while koro is culture-bound syndrome found in South and East Asia which is a phobia or extreme fear that one’s penis will shrink inside one’s body. Eating disorders, such as anorexia nervosa and bulimia are more prevalent in Western cultures or where Western-cultural influence is more abundant, leading some researchers to claim that they are, in fact, culture-bound syndromes.

Mental disorders which are found across the world regardless of culture are known as universal syndromes. Researchers purport that universal syndromes tend to have a biological root, meaning that culture place less of a role. Nevertheless, perceptions of these particular disorders by members of a certain cultures may be uniquely influenced by said culture. Universal disorders include depression, schizophrenia, social anxiety disorder, and bipolar disorder, for example.

ADHD appears to be a universal syndrome, although perceptions of the disorder or the degree to which it is pathologized or normalized varies widely across cultures. Although perceptions and/or attitudes toward other mental health disorders (such as major depressive disorder or schizophrenia, for example) may vary somewhat across cultures, perceptions and/or attitudes towards ADHD may vary much more widely than other mental health disorders. This may make ADHD unique in this regard.

Nevertheless, there are mental health professionals and researchers who claim that ADHD is simply a cultural construct. They cite the lack of “specific cognitive, metabolic, or neurological makers and no medical tests for ADHD” to support this assertion (Timmi and Taylor, 2004).  Eric Taylor, a psychiatrist in the UK, argues that ADHD is a cultural construct. He states that there are “no specific cognitive, metabolic or neurological marker and no medical tests for ADHD.” Although this may be accurate to some degree, this is the case for most all mental disorders. Indeed, mental disorders may not be identifiable via standard medical tests, such as blood tests or tissue biopsies.

Taylor reports that brain imaging studies are not able to determine if there are abnormalities in the brains of children with ADHD and that any differences found are inconclusive; that is, the differences cannot be said to be the cause of the ADHD symptoms. Furthermore, comorbidity is very high in people with ADHD; therefore, it could be argued that many other factors cause ADHD symptoms observed. Perhaps, ADHD-like behaviors are better explained by other disorders, according to Taylor.

Taylor believes that the only way to explain the rise in the prevalence of ADHD is by a shifting cultural perspective. He believes that changes in culture have led to an increase in ADHD diagnosis. For example, there are many factors that adversely affect the mental health of children and people in general. This includes breakdown in families (more single-parent families), parents less willing to discipline their kids (i.e., teach appropriate behaviors), schools which are over-stretched, and an economic system which emphasizes individuality and competiveness. Taylor believes that many families lead a “hyperactive lifestyle,” as well, which leads to children learning hyperactive behavior. Taylor concludes, that all of this combined may be more difficult to change than to simply create a disorder and blame the child.

Taylor goes on to argue that a medical model for ADHD is not helpful. He believe it simplifies the problem and leads to doctors, parents, and teachers disengaging from social responsibility. Instead they come up with a “cultural disorder” in which they purport to have a cure.

On the other side of the argument Timimi believes that ADHD is neither a genetic disorder nor a social construct, but rather the interaction of the two which results in ADHD. Timimi cites research which points out that there are difference in brain structure, especially in regards to the dopamine system. Furthermore, he states those from all socioeconomic statuses are affected by ADHD, which he believe supports the idea of it being an actual disorder. He goes on to state that two studies 20 years apart in the UK showed that rates of ADHD have been mostly stable over time.

In short, he admits that social factors may play a role, but he does not believe that ADHD can be relegated to a cultural or social construct. He believes that it is more complex than that. Timimi also states that in the UK, ADHD is more likely to go underdiagnosed; however, he acknowledges it can be over diagnosed in some cultures, such as in the US.

However, some research has found a correlation between socioeconomic status and ADHD, with those coming from a lower socioeconomic status having higher rates of ADHD. In fact, financial difficulties was found to be the strongest predictor of ADHD. This, however, does not necessarily mean that ADHD is not an actual disorder and simply the result of a disadvantage upbringing. For example, people from lower socioeconomic status are at greater risk for many disorder, such as diabetes and schizophrenia (Russel et al., 2015).

What is more likely is that there is an interplay between environment, genetics, as well as psychological and sociological factors which either leads to the development of ADHD symptoms or an exacerbation of the symptoms. Furthermore, those from disadvantage backgrounds may not have timely access to appropriate treatment which may cause ADHD to worsen, as well further lead to other complicated problems, such as depression, anxiety, or substance abuse (Russel et al., 2015).

Although ADHD is found across multiple cultures, diagnostic rates vary widely. For example, rates in France……USA…..Korea…… This variability in diagnostic rates is believed to be due differences in what is regarded as normal childhood/adolescent behavior versus abnormal behavior across various cultures. For example, diagnostic rates in Mexico are believed to be lower, as Mexican culture tends to be more tolerate of behaviors that may be considered ADHD, such as hyperactivity and impulsivity. On the other hands, cultures where children are expected to sit quietly and inhibit their impulses, such as in the USA or Japan, diagnostic rate are often higher. Indeed, misdiagnosis is always a possibility. Some cultures may result in under diagnosis of ADHD (such as in Mexico) or over diagnosis (such as in the USA).

In addition to cultural influence on perceptions of ADHD, culture may have an influence on a society’s propensity to medicate ADHD. Although the United States consume about 80% of the world’s Ritalin, the International Narcotics Control Board reported that Iceland consumed slightly more Ritalin per capita than the United States. Furthermore, the consumption of Ritalin has increased a great deal all across the globe in multiple nations surveyed. The one exception was Israel, where consumption rates dropped slightly (Singh, 2008. One may deduce that the increase in consumption or Ritalin across the globe points toward greater awareness of ADHD and pharmacological treatments.

However, even within a particular culture diagnostics rates can vary. In the United States, Reid revealed in his study that ADHD rates tend to be higher in certain ethnic groups (1998). For example, ADHD rates in African-Americans and Hispanic-Americans are higher than rates amongst Caucasians. Although it is possible that there are certain conditions within these ethnic groups which may result in higher rates, it may also be possible that ADHD assessment instruments are misleading or invalid for certain ethnic groups (Reid, 1998). Reid points out, however, that socioeconomic status was not taken into account for his study (1998). Therefore, it is possible that the differences in ADHD rates between ethnic groups may have been influenced by socioeconomic status (Reid, 1998). According to Russell, ADHD rates are often higher in those from lower socioeconomic status (Russell, 2015).

ADHD rates in Thailand appear to be somewhat lower than in Western cultures; however, studies on ADHD in Thailand are very limited. Barkley, et al. reported that ADHD rates are lower in Thailand due to cultural factors which train children to speak quietly in public and encourage obedience to authority figures (1987). Although is some truth to this, this would not necessarily identify children with ADHD, Inattentive type (since these children are rarely disruptive).

Studies have shown that the prevalence of ADHD varies widely across cultures, with a worldwide prevalence estimated to range between 2.2% and 17.8% (Skounti, Philalithis,& Galanakis, 2007). However, this variability in the rates of ADHD could possibly be explained by the reality that the perception of ADHD can vary across cultures (Bussing, et al., 1998). Furthermore, “whether individuals and communities perceive the behaviors associated with ADHD as problematic depends on a given culture’s acceptance of the problem behaviors associated with ADHD and their occurrence in children (Al Azaam, 2011).”

According to one study, Korean culture view symptoms of ADHD in children as a failure of teachers and parents. Therefore, Koreans may fail to recognize symptoms of ADHD as a disorder, but rather blames themselves—viewing themselves as inadequate parents or teachers. As such, parents and/or teachers are often reluctant to seek out assistance for dealing with children with ADHD (such as from psychologists and counselors) out of fear of being judged negatively by other family members or colleagues (Hong, 2008). Indeed, Singh states that ADHD is poorly understood in Korea, combined with a culture which places blame on parents and educators, it is logical that rates of ADHD reported in Korea would be lower when compared to other countries. However, in fact, lower rates of ADHD in Korea may be the result of perception rather than actual lower rates (2008).

ADHD rates in Thailand may be lower due to multiple reasons. For example, there may be less awareness amongst Thai society of ADHD as a disorder, leading Thai people to regard symptoms of ADHD as either normal child or adolescent behavior or as behavior that is willingly disruptive. Additionally, children and adolescents who display such behaviors may be regarded as “stubborn,” “bad,” or “stupid.” That is, children with ADHD in Thailand may be mislabeled rather than slotted for treatment, leading only to the appearance of lower rates instead of actual lower rates.

On the other hand, it is possible that there are in fact lower rates of ADHD in Thailand due to certain factors, such as culture and/or family upbringing. Indeed, culture has a strong influence on the expression of various mental disorders. However, it is also possible that perceptions of what constitutes ADHD or awareness of ADHD in Thailand gives the appearance of lower ADHD rates. Culture, perception, and actual pathology interact—leading to what is reported as ADHD rates in any given society.

Thus, to completely understand how to identify and treat ADHD, it must be studied from within a cultural perspective. Research suggests that ―culturally-relevant factors, like beliefs and values regarding child behavior, impact the way members of various ethnic and cultural groups view and respond to problematic behavior in children (Al-Azzam, 2011).

The focus of the present research is to examine rates and perceptions of ADHD in Thailand in order to gain a clear picture of ADHD in Thailand. One way to examine how culture may influence rates of ADHD is to examine parental and educators’ perceptions of what should be deemed normal problematic behavior or behavior resulting from pathology.

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