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Wide Global Variation in ADHD Diagnosis and Treatment

Fran Lowry



2011 — Different countries have different attitudes toward attention-deficit/hyperactivity disorder (ADHD).

In a study appearing in the May issue of Psychiatric Services, researchers, led by Stephen P. Hinshaw, PhD, report that the prevalence of ADHD varies across nations but that most of this difference is due to disparate diagnostic practices and algorithms.

Dr. Hinshaw, from the University of California, Berkeley, and his team note that ADHD is recognized around the world as a chronic neurodevelopmental disorder that leads to impairment and the need for treatment.

"Concerns have been raised about cross-national variation in the prevalence of ADHD, under the assumption that cultural differences are likely to underlie disparities between countries," they write.

But more recently, a meta-analysis indicated that differences in prevalence are largely attributable to methodologic differences in the studies themselves rather than cultural or national factors.

In the current study, the investigators asked 18 researchers who were participants in an international conference on ADHD to review literature, history, and current practices in their country and respond to questions about the diagnosis, treatment, payment systems, and beliefs in the educational system about ADHD in different locations.

The conference took place in 2010, and the countries involved were Australia, Brazil, Canada, China, Germany, Israel, the Netherlands, Norway, the United Kingdom, and the United States.

The study showed that use of both medication and psychosocial treatment for ADHD varied widely within and across nations.

Drugs 'Out of Favor' in Brazil

All 10 nations reported that the use of more expensive long-acting formulations of medications was becoming more widespread.

In some countries, medications were considered as first-line treatment, but in others, psychosocial treatments were tried before drugs. For example, in the United Kingdom, treatment guidelines advocate that psychosocial treatments be used first in many cases, and in Canada, the use of medication and psychological interventions is left up to physician and patient preferences.

In Brazil, psychoanalysis was the mainstay of treatment and use of drugs was "decidedly out of favor"; also behavioral problems were not viewed as related to clinical manifestations of syndromes or disorders. Many of the respondents cited physical exercise as being a viable option instead of medication for ADHD.

In China, where children are under strong pressure to achieve at high levels in school, attention and deportment have become problematic. Also use of methylphenidate medication is difficult because the government-run health system mandates that any prescriptions be given for a maximum of only 2 weeks. "Such stringent guidelines curtail use of this intervention," the study authors write.

Countries with socialized medical care were more likely to provide an array of evidence-based interventions, the study authors noted.

Too Quick to Prescribe?

"It's almost like ADHD is a religious experience and there are believers and nonbelievers," said R. Scott Benson, MD, a psychiatrist from Pensacola, Florida, who specializes in treating children and teenagers with ADHD.

Different cultures have different approaches to ADHD, Dr. Benson, told Medscape Medical News.

"The authors are showing that different places have different approaches, and these are based on many factors, such as the country's general cultural belief about children and learning or the economic system that supports healthcare or limits access to healthcare," he said.

Dr. Benson illustrated his point with the following example:

"One of the things they require in Germany, and they can do it because of the way their health economy is structured, is that parents who are concerned about the possibility of ADHD in their children must try to learn parent-training strategies before the doctors start writing prescriptions for medicine," he said.

"But because of the way our health economy is structured, we don't do that much counseling — parent training is not an element that we put in. In our culture, I think we're a little quick to reach for prescription pads."

This study was supported in part by an Investigator Award in Policy Research from the Robert Wood Johnson Foundation. Dr. Hinshaw and Dr. Benson have disclosed no relevant financial relationships.






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