In Israel, highly active children are well tolerated in the classroom, making it difficult to distinguish high activity from
attention-deficit/hyperactivity disorder (ADHD) manifestation. In Brazil, light physical punishment is considered by a large
number of teachers to be "therapeutic," and physical exercise is considered a viable alternative to medication for children
with ADHD. In Canada, health professionals view ADHD as an impairing, often lifelong disorder that requires careful assessment
and multimodal intervention.
These are just a few of the insights that came out of a meeting of 18 international leaders in developmental psychopathology
research who met in Berkeley, Calif., in March 2010. The members represented nine countries—Australia, Brazil, Canada, China,
Germany, Israel, the Netherlands, the United Kingdom, and the United States—all specifically selected because they were known
to have either low or high rates of diagnosis and treatment of youth with ADHD. The group published a report in the May Psychiatric Services.
Stephen Hinshaw, Ph.D., lead author of the report, is a professor and chair of the Department of Psychology at the University
of California, Berkeley, a fellow of the American Association for the Advancement of Science, former president of the Society
of Clinical Child and Adolescent Psychology, and a member of the International Advisory Board on Stigma and Discrimination
in the United Kingdom. His research focuses on mental disorders affecting children and adolescents, particularly ADHD.
"With our limited resources for this initial look at the issue, we concentrated on high versus low," Hinshaw told Psychiatric News. "Ideally, larger investigations can further examine the whole range of rates of diagnosis and treatment. We were attempting
a first-pass, qualitative, and quantitative analysis; we knew our results would be suggestive, not definitive."
The group considered these questions when they met:
What system is used to diagnose ADHD, and which professionals are most involved in assessment and diagnosis?
What is the treated prevalence of ADHD in terms of medication?
Which medications are used, what is the relative share of each, and which professionals are involved in medication treatments?
Which psychosocial treatments are used, what is the treated prevalence, and what is the relative share of each?
What payment systems are used for treatments, and where are treatments "located" in the service-delivery system?
What are the predominant beliefs in the education system with respect to assessment and treatment of ADHD?
For adult ADHD, what are current trends in prevalence and treatment?
What key cultural, historical, or national influences are related to ADHD treatment?
They found that although the prevalence of ADHD varies across nations, largely due to disparate diagnostic practices and algorithms,
far larger international variability exists with respect to treated prevalence and treatment procedures.
"The most surprising finding from this collaboration is the incredible range of ADHD service-delivery systems internationally,
from highly organized and integrated on the one hand to barely acknowledging the existence and importance of ADHD on the other,"
Even as all nations have witnessed large increases in use of medication for ADHD, and even as evidence-based psychosocial
treatments have gained credence, there is still a major struggle to provide care, said the group.
"Initial feedback to this effort indicates strong interest," said Hinshaw. "Many out there are wondering how to span basic
science, clinical trials, and policy efforts to provide evidence-based, comprehensive care for those with ADHD."
Work on the report was partly supported by an Investigator Award in Policy Research from the Robert Wood Johnson Foundation.
Additional funds were provided by the Center for Child and Youth Policy, the Nicholas C. Petris Center, and the Department
of Psychology, all of the University of California, Berkeley.
"International Variation in Treatment Procedures for ADHD: Social Context and Recent Trends" is posted at <http://ps.psychiatryonline.org/cgi/content/full/62/5/459>.