The prevalence, diagnosis, and treatment of ADHD around the world varies due to a number of factors.
This includes differences in culture, education, public perception, and medical opinion regarding the nature, diagnosis, and treatment of the condition.
For instance, compared to the US, some countries report a far lower prevalence of ADHD among the population and treat ADHD with little reliance on stimulant medication.
A cross-cultural meta-analysis of ADHD around the world provides a useful big picture view that not only leads to a better understanding of the condition, but helps us improve diagnostic and treatment methods in order to best help ADHD sufferers everywhere.
Let’s get started...
In the United States, approximately 12% of school-aged children (7-19% depending on the study) have been diagnosed with ADHD and up to two-thirds of those diagnosed are taking stimulant medication such as Ritalin, Adderall, etc.
This represents roughly 6.4 to 12 million children.
There has also been a 53% increase in ADHD diagnoses over the past decade. This is due, in part, to increased knowledge and awareness of the condition among parents, teachers, mental health professionals, etc.
Roughly 19% of high school age boys (14-17) and 15% of all school-age boys in the US have been diagnosed with ADHD.
Similarly, roughly ten percent of high school-age girls and 7 percent of all school-age girls have likewise been diagnosed with ADHD,
There is a public perception that ADHD only affects boys, but this is incorrect. In fact, many researchers believe that the number of diagnosed girls in the US is low because of this misperception, and results in girls not getting accurate diagnosis and treatment.
ADHD Prevalence By State
Even within the US, there is a difference in prevalence rates of ADHD between states.
For example, Centers For Disease Control (CDC) statistics report that more than 13% of children in the deep south states such as Alabama, Mississippi, and Louisiana are currently diagnosed with ADHD, while the prevalence of ADHD among schoolchildren in Nevada is less than 7%.
Attention Deficit is diagnosed using the diagnostic criteria found in the Diagnostic and Statistical Manual Of Mental Disorders (DSM). This manual is used by mental health professionals (psychiatrists, psychologists, clinical social workers, licensed professional counselors, etc.) to diagnose mental health conditions.
The DSM is basically a checklist of symptoms, and if a person meets the threshold number of symptoms for a given condition over time, a diagnosis is given.
It is important to note that mere hyperactivity alone is not sufficient to diagnose ADHD. After all, most children display hyperactivity. Rather, symptoms must be consistently present for at least six months prior to an official diagnosis being given.
Diagnosis of ADHD in the US is often given after only one brief office visit, and doctors typically do not explore other factors that may contribute to a child's behavior.
The most common way to manage ADHD symptoms in the US is through the use of ADHD medications such as Ritalin, Adderall, etc. In my clinical experience, these stimulant medications tend to work best in those with severe ADHD, but they can cause side effects (nausea, headaches, insomnia), can be habit-forming, and tend to lose their effectiveness over time.
Conventional psychiatry in the United States generally views ADHD as a bio-neurological disorder with biological causes. It is currently considered a chronic brain condition that lasts into adulthood and can have long-term negative impacts on school achievement, adult employment, social relationships.
In France, .5% of children are diagnosed with ADHD. The prevalence of ADHD in France in much lower compared to other countries due in part to differences in the field and psychiatry and how the condition is diagnosed.
While France uses its own version of the DSM checklist of behaviors to help diagnose ADHD, it is far less broad than the American DSM which leads to lower rates of diagnosis.
In contrast to the American approach, French psychiatrists tend to view a child in a greater bio-psycho-social context to attempt to identify the underlying causes of a child’s behavior. This may include efforts to identify possible environmental and social factors, food allergies, and any other behavioral triggers that may be related to a child’s behavior.
The French approach considers the “whole person” which most agree provides more valuable therapeutic insight.
Another significant difference is that French mental health professionals generally do not rush to medicate ADHD children, but prefer to treat problem behavior and ADHD symptoms with therapy and counseling.
French doctors report less reliance on stimulant medications such as Ritalin, Adderall, etc.
Parenting Styles and Lifestyle Differences
According to surveys and studies, French parents tend to provide more structure and better enforce boundaries and limits compared to American parents. Rules of behavior are well understood, which results in greater self-control among French children.
Also, the French emphasize a nutrient rich diet with far less emphasis on the processed and fast foods found in the American diet. (Research studies indicate that gluten, artificial colors and preservatives, and processed sugars/high fructose corn syrup can contribute to ADHD symptoms.)
French families also tend to eat together, eat the same food (no kids menus), and snack less.
While these cultural factors likely play a role in the differences in ADHD diagnosis and treatment in France, we do not yet know the full extent.
Prevalence And Diagnosis
The overall lifetime prevalence of ADHD in Germany is roughly 4.8% of the population, with a significant gender difference between school-age boys (7.7% - 10%) and girls (1.8% - 2.3%). Significant age differences are noted too between pre-school (1.5%), primary school (5.3%), and secondary school (7.1 - 10%).
There is also a difference in ADHD diagnoses by socioeconomic status: low SES (6.4%), medium SES (5.0%), and high SES (3.2%).
Early childhood education in Germany often involves an outdoor component. They even call it the Waldkindergärten (“forest nurseries” or “forest kindergarten”) and this approach likely benefits ADHD students who tend to dislike institutional classroom settings.
These outdoor classrooms teach children a wide range of skills and abilities such as fine motor skills, survival skills (building fires, tools, shelter, etc,), social cooperation (important in all aspects of life), observing and respecting nature, animals, seasonal changes, etc.
These activities also teach children emotional intelligence, self-confidence, and provide a greater breadth of experience. Research indicates that the more senses that are utilized in the learning experience, the deeper the learning process.
Finland tops the world in academic performance, and one of the notable features of Finnish classrooms is frequent breaks and the importance of recess. Children are typically given a 15 minute recess for every 40 or 45 minutes of classroom instruction.
Exercise has been shown to reduce ADHD symptoms because exercise provides an increased flow of oxygen and nutrients to the brain which improves focus and concentration, reduces hyperactivity, and helps improve mood. These breaks allow children to blow off steam and the teachers to take needed breaks, grab a coffee in the lounge, etc.
This is in stark contrast to the US where most public school students enjoy one recess period per day.
In addition, teaching is a respected, highly credentialed profession in Finland that pays as well as some doctors and lawyers. In viewing the treatment of ADHD around the world, Finland manages to serve and educate ADHD students in school settings better than most other countries.
Canada and the UK are grouped together due to their statistical similarities with respect to ADHD prevalence and treatment.
ADHD is the most common childhood mental health disorder in both nations, affecting between 5% and 10% of school-age children. Boys are diagnosed more than girls at a ratio of 3-to-1.
Diagnosis and treatment are typically conducted by the public health system of each country, and stimulant medications are the most common form of medical management.
Similar to the US, there has been a 50% increase of ADHD in England over the past six years. and the UK’s Care Quality Commission reports that NHS (National Health Service) prescriptions for stimulant medications (Ritalin, etc.) rose from 420,000 in 2007 to 657,000 last year. There has been a large increase in Canada too, but not as dramatic.
Stimulant medications such as Ritalin, Straterra, and Dexedrine are licensed in the UK, but Adderall is not currently provided by the NHS. (However, it may be available through private psychiatrists.)
Adderall is currently available in Canada but was temporarily suspended in 2005 for it’s potential link in the sudden death of 12 children and adolescents.
For much of the world outside of North America and Western Europe, it is difficult to fully ascertain the rate of occurrence of ADHD. There is simply not enough research in this area, so we can only calculate estimates based on extrapolations.
While there are differences in prevalence, perception, diagnosis, and treatment of ADHD around the world, does this indicate that ADHD is mostly a social construct? A byproduct of American culture? No, I don’t think so.
A journal articled titled "The Worldwide Prevalence of ADHD: Is It An American Condition?" (World Psychiatry, 2003) conducted a meta-analysis of prevalence rates of ADHD around the world. It concluded that the prevalence of ADHD is at least as high in many non-US children as in US children (but with the highest prevalence rates occurring when using DSM diagnostic criteria.)
More importantly, through the use of brain scan technology (particularly the work of brain researcher Dr. Daniel Amen), we can literally see brain differences in a person with ADHD compared to one without ADHD.
While there are certainly cultural and other mediating factors, ADHD appears to be a cross-cultural disorder.