cultural factors in the diagnosis and treatment of ... · cultural factors in the diagnosis and...
TRANSCRIPT
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