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1 Introduction

Attention deficit hyperactivity disorder (ADHD), or attention deficit disorder (ADD), is globally recognized as a disorder with an onset in childhood. Over the years, the nomenclature of this neurobiological disorder has changed and the use of a collapsing or expanding set of criteria has influenced how the diagnosis is made and coded in various versions of the diagnostic and statistical manual (DSM) of psychiatric diagnoses. The DSM taxonomy has been criticized for its categorical and nondimensional approach in describing symptoms that occur in the normal continuum of human behavior. Attention span, impulse control, and varying levels of energy are common variables in human behavior that become difficult to categorically define as normal and abnormal. Yet the DSM remains a major reference for an international nomenclature for psychiatric illness. In mid-2013, the new DSM 5 was published and currently acts as a guide for the clinical practice of psychiatry. The focus of this chapter will be to present the current understanding of ADD and a synopsis of what the changes in the criteria set for ADHD/ADD are in the DSM 5 in comparison to DSM IV R.

This chapter examines the new and revised criteria for ADHD/ADD and provides the reader rationale for the changes in DSM 5 while providing a brief overview of assessment treatment strategies focusing primarily on the child and adolescent population. Clinical vignettes will help illustrate how these changes will influence practice.

Although international studies conducted to look at the incidence of ADHD worldwide show that the prevalence of the disorder is similar across cultures, there may be a difference in the way ADHD/ADD are viewed in the South Asian subcontinent versus Western cultures. This perspective will be explored using a vignette demonstrating how an ADHD/ADD diagnosis and treatment plan differs and is similar in two cultures.

ADHD is a well-established psychiatric disorder beginning in childhood, which persists into adulthood. During the aftermath of World War I and after epidemics of encephalitis, symptoms which would be indistinguishable from ADHD today were described by Kramer and Pollnow (1932) including inattention and hyperactivity in children and adults. Bradley (1937) accidently discovered that Benzedrine, the most potent stimulant available at that time used to treat headaches in neurologically impaired children arising from pneumoencephalographic studies, did little to cure the headaches but significantly reduced motor restlessness such as that described by Kramer and Pollnow (Rafaelovich 2001; Rothenberger and Neumacher 2005). Benzedrine was replaced by methylphenidate as an agent to reduce hyperactivity as early as 1944 (Morton and Stockton 2000; Rothenberger and Neumacher 2005) and remains the mainstay of modern day treatment of ADHD.

This syndrome has been conceptualized in varying ways as evident from its nomenclature over the past century: minimal brain dysfunction, hyperkinetic reaction of childhood, etc. The DSM has been the most influential source for psychiatric classifications internationally and the five preceding versions have been a singular influence on the clinical usage of psychiatric terminology as well as in education and scientific research.

However, there have been many criticisms raised about the prior DSM classifications. There is recognition that human behavior is a complex phenomenon and it can be described better on a dimensional continuum rather than the categorical scale the DSM uses. Most human behavior is determined to be aberrant based on subjective experiences and although extreme behavioral aberrations can be classified as being abnormal, minor variants are subjective and anchored in the concept of social and occupational functionality, which is usually difficult to quantify and is thus open to criticism. In addition, the DSM has worked well for describing behavior but with minimal emphasis on the etiology or the phenomenology of a disorder. Despite these criticisms, it still serves as a common and unifying language to catalogue psychiatric disorders that allow mental health practitioners across the globe to communicate and conduct ongoing clinical research.

The DSM 5 (the new nomenclature abandoned the Roman numerals) published by the American Psychiatric Association (APA) in the summer of 2013 was the first revision since 1994 and was eagerly awaited, as there was general consensus that the DSM IV (IV Revised) had poor validity; was based on clustering of symptoms that clinicians were following inflexibly but often inconsistent with clinical presentations; and had unexplained and excessive comorbidity creating confusion. Overall, there were too many disorders listed with questionable scientific validity (Reigier et al. 1998). This revision was based on the work of a multiyear task force appointed by the APA that worked in the form of study and work groups. They organized their work around diagnostic spectra, lifespan and development of disorders, effect of gender and culture, psychiatric and medical issues, degree of impairment and assessment mechanisms, and also aligned it to the International Classification of Disease-11 (ICD 11) system of medical disorder classification. The work groups took into consideration scientific evidence and attempted to balance it against clinical utility and experience.

Irrespective of agreement or disagreement with the manner in which the changes in the nomenclature have occurred, it is imperative to become familiar with them and how they impact changes in practice. In addition, it would be interesting to examine how these changes affect clinical work in this area globally and how ADD is similar or different in Asian countries versus the United States. Illustrative examples of how the syndrome may differ and be similar in South East Asia versus the western diaspora will be provided as vignettes. Etiology and treatment considerations for ADHD will also be discussed.

2 DSM 5 Changes

Metastructure and place in classification:

The DSM 5 metastructure aligned its classification system with the ICD 11 within which the F-0 subsection is the neurodevelopmental disorder category. For the first time, ADHD was shifted from the group of frequently comorbid disorders of conduct, oppositional and disruptive disorders to the neurodevelopmental disorder category. This category includes Intellectual Disability, Autism Spectrum Disorder, Communication Disorder, Developmental Motor Coordination disorder, and Specific Learning Disorder.

Clinical criticism of the DSM IV TR classification of ADHD (Willcutt et al. 2012):

  1. 1.

    Lack of scientific basis for age-at-onset criterion

  2. 2.

    Questionable validity of subtypes

  3. 3.

    Developmental insensitivity of symptoms and thresholds for adults, including inadequate coverage of impulsiveness

  4. 4.

    Presence of autism/pervasive developmental disorder (PDD) as diagnostic exclusion

The following section will elaborate on the fundamental differences introduced into the DSM 5.

  1. 1.

    Age at onset of criteria for ADHD

The previous understanding of when and how ADHD presents was strongly focused on childhood. There was the general assumption that if the disorder had not been identified by age 7, later onset of symptoms ought to be explained by other disorders or secondary to psychosocial events that the child may be reacting to. Not too far back, ADHD as a disorder of adulthood was likewise not recognized. However, in the past two decades there is an increasing appreciation for the adult manifestations of the disorder. As part of the diagnosis, the previous age criteria would send clinicians on an appropriate but frustrating mission to establish early onset of the disorder while obtaining data from adults who were clearly impaired but could not recall when they began to show symptoms. Other investigations of subjective recall of when symptoms of ADHD began and a meta-analysis of the literature (Keiling et al. 2010) did not support the 7-year age in criteria B which stipulates that “Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years,” as having scientific merit. This loosening of the age criteria caused concern that this would increase the prevalence of ADHD incorrectly. However, further analysis of the implication for prevalence rates due to less stringent age criteria indicated that there would be no increase in base rates (Polanczyk et al. 2010). Hence, the new age threshold has been increased to 12 years.

Summary: Age by which a formal diagnosis of the disorder must be made has been raised from 7 to 12.

Below is a vignette of the adult form of ADHD.

Case 1: JJ is a 27-year-old referred to the University Counseling Center (UCC). He is a fellow in cardiology but is having a tough time completing his work, is often late to rounds and is frustrating his training director who cannot understand why such a bright individual can be so unpredictable in his performance. On interview, the UCC Child and Adolescent Psychiatrist (CAP) decides that he is not depressed, has always done very well academically (as his admission to medical school proved) and ADHD could not possibly be in the differential diagnosis.

On a further detailed history, his tested IQ is 140 and although constantly “on the move” as a child, he was charming and managed to do well in grade school. In high school he took five Advanced Placement courses and struggled through them but yet made it into a prestigious undergrad college. It was in medical school that he became progressively more erratic in his performance. When focusing on one area he would get behind in others. Finally residency, with its demanding schedule and multitasking, took its toll and he became paralyzed into inaction with poor attention to detail, often late, and missing deadlines. The CAP understood this history as that of a highly compensated individual who had managed his ADHD until now.

Family history was positive for ADHD in paternal uncle.

A trial of stimulant medications produced steady improvement and removal from probation.

  1. 2.

    Validity of subtypes of ADD in DSM IV

The DSM II description of ADD separated the classic triad of attention, hyperactivity, and impulsivity, while the DSM III lumped them all together. In the DSM IV and IV-R, ADD was subtyped into either inattentive or hyperactive/impulsive or a combination of the two. In anticipation of the DSM 5, a meta-analysis of 431 studies (Willcut et al. 2012) lead the authors to conclude that the DSM–IV ADHD subtypes provide “a convenient clinical shorthand to describe the functional and behavioral correlates of current levels of inattention and hyperactivity/impulsivity symptoms, but do not identify discrete subgroups with sufficient long-term stability to justify the classification of distinct forms of the disorder.” In the face of this study and clinical experience of experts, it did not appear justified that these subtypes became lifetime diagnoses. As a result, the current criterion for subtypes is renamed “specifiers” of current functioning: either the inattentive or hyperactive/impulsive or combined presentation but stipulates that these descriptors merely describe the most current presentation and that this could change with time. In addition, these symptoms are rated as mild, moderate, or severe.

Summary: In DSM 5, there are no more subtypes but specifiers, which are the inattentive, hyperactive/impulsive or combined reflecting current presentation. These specifiers have a potential for change over time. The severity of the specifiers has to be coded as mild, moderate, or severe.

  1. 3.

    Developmental insensitivity of symptoms and thresholds for adults, including inadequate coverage of impulsiveness, severity thresholds and impairment

The development of the diagnostic criteria for ADD goes back to the 1950s when this was considered a disorder of children and considered to dissipate by puberty. Hence, examples of what constituted inattention, hyperactivity, or impulsivity were reflective of commonly observed aberrations that were developmentally related to childhood. With the recognition that ADD persists into adulthood, often with disabling symptoms that are distinct to adulthood, there has been a push to include adult examples of inattention, hyperactivity, and impulsivity as well as reduce the threshold of symptoms to meet diagnosis from six to five.

The DSM 5 provides examples of how these symptoms manifest across age ranges, including ways they would appear in older adolescents and adults. Thus, although the symptom list remains the same, the inclusion of developmentally appropriate examples helps guide clinicians evaluating older adolescents and adults (Keiling et al. 2010).

The nine inattentive symptoms are:

  • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

  • Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

  • Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the work place (e.g., starts tasks but quickly loses focus and is easily sidetracked).

  • Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

  • Often avoids or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults: preparing reports, completing forms, reviewing lengthy papers).

  • Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and mobile telephones).

  • Is often easily distracted by extraneous stimuli (e.g., for older adolescents and adults may include unrelated thoughts).

  • Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults: returning calls, paying bills, keeping appointments).

The nine hyperactive-impulsive symptoms are:

  • Often fidgets, taps hands, or squirms in seat.

  • Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

  • Often runs about or climbs in situations where it is inappropriate (e.g., in adolescents or adults, may be limited to feeling restless).

  • Often unable to play or engage in leisure activities quietly.

  • Is often “on the go” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

  • Often talks excessively.

  • Often blurts out answers before questions have been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

  • Often has difficulty waiting turn (e.g., while waiting in line).

  • Often interrupts or intrudes on others (e.g., joins into conversations, games, or activities uninvited; may start using other people’s things without asking or receiving permission; for adolescents and adults: may intrude into or take over what others are doing).

In addition, the threshold for diagnosis of ADHD has been reduced for individuals 17 or older in recognition of the clinical observation that many of the symptoms decrease with maturity and that a reliable diagnosis can be made by fewer positive symptoms in older individuals. The 6/9 criteria remains for the below 17 year age individuals while it is five or more for 17 and older.

Overall, the explanations for comparable symptoms in adults are a helpful addition to clarify how the criteria are applicable to adults.

The criteria for impairment has been reduced to “…clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.” This reduction in stringency could increase the rates of a diagnosis of ADHD. Decisions regarding functional impairments are often subjective and value judgments that clinicians routinely make that heavily affect the ultimate diagnosis. However, future research data will be the only way to determine if the base rates of the diagnosis increase. These examples underscore the need for multi-informant information and use of rating scales that are normed over large populations such as the ADHD-IV Rating Scale (DuPaul et al. 1998) or the Vanderbilt Rating Scale (Wolraich et al. 2003).

DSM-5 also requires clinicians to specify the severity level of a client’s ADHD as Mild, Moderate, or Severe.

Mild is restricted to cases where there are few, if any, symptoms beyond those required to make the diagnosis and no more than minor impairment in functioning.

Moderate is simply defined as symptoms or functional impairment between “mild” and “severe.”

Severe is a term reserved for cases with many symptoms in excess of those required for the diagnosis, or several symptoms that are especially severe, or marked.

DSM-IV had a category called ADHD Not Otherwise Specified (NOS) for individuals who displayed prominent symptoms but who did not meet required criteria.

In DSM-5, this has been changed to Other Specified ADHD and Unspecified ADHD. The former is used when full criteria are not met, symptoms that are present create clinically significant distress or impairment in functioning, and the clinician chooses to convey why full criteria are not met, for example “Other specified ADHD with insufficient inattention symptoms.”

  1. 4.

    Presence of autism/PDD as diagnostic exclusion

As one recalls from the past, the diagnosis of ADHD could not be made with a concurrent diagnosis of autism. The assumption was that hyperactivity was a part of the autism spectrum disorder and did not reflect a separate disorder. The DSM IV stated, “The symptoms do not occur exclusively during the course of a PDD, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder.” In DSM 5 this has been changed to “The symptoms do not occur exclusively during the course of schizophrenia or other psychotic disorder and are not better accounted for by another mental disorder.”

Overall, this is a positive change to the criteria and appears clinically sound. It acknowledges the clinical approach to treatment of inattention and impulsivity often seen in conjunction with autism and is reflective of the neurodevelopmental pathogenesis of the symptoms. Below is a case vignette demonstrating how these changes may be utilized in clinical practice.

Case 2: AD is a 6-year-old child with a diagnosis of autism since age 2. For the past seven months he has had troubling temper tantrums. The behavior has curtailed the parent’s ability to take him to any public place. In the special school he attends, his teachers have noted that he is “busy” and despite their best efforts cannot be redirected. He strikes other children. When more detailed information is obtained about the triggers and antecedents to the behavior, it becomes clear that he does so when he cannot get his way or when he is stopped from engaging in any activity. He is noted to jump from activity to activity and cannot sit still. Overall he is not moody or angry except during these episodic events. If prepared adequately, he handles transitions appropriately. The most likely explanation to these “new tantrums” is emerging impulsivity (and hyperactivity) rather than impairment arising from mood or transition difficulties. When he has the need to do something or acquire something he is not able to curb the impulsive need to fulfill that desire and gets disruptive. Use of redirection and behavioral interventions is partially successful but a trial of a stimulant produced marked compliance and improved adjustment in the classroom. The importance of recognizing the etiology of the “tantrums” has implications for the choice of somatic treatments.

Brief Summary of Etiology:

From the multiple elements that contribute to the etiology of ADHD, it is reasonable to assert that it is a disorder uniquely multifactorial and has its origins in genetics, familial and environmental factors, and (multiple) neurotransmitters. This complexity makes predictions about developmental trajectory and response to treatment complicated at best.

Genetics: Family and twin studies have strongly and consistently supported that ADHD runs in families (Freitag and Retz 2010) Twin studies suggest that ADHD has a high heritability factor and attribute about 80 % of the etiology of ADHD to genetic factors (Larsson et al. 2004). Adoption studies of ADHD also implicate genes in its etiology. In addition, the correlation of DRD4 and DAT transporter genes and ADHD (LaHoste et al. 1996) reinforce the neurobiological foundation of the disorder.

Neurotransmitters

Structural and functional imaging studies consistently implicate catecholamine-rich fronto-subcortical systems in the pathophysiology of ADHD (Volkow et al. 2007). Given the mode of action of stimulants and their effectiveness in the management of ADHD, catecholamine disruption as at least one source of ADHD brain dysfunction (Berridge et al. 2006) is a plausible neurotransmitter-based model to understand ADHD. Although not entirely sufficient, changes in dopaminergic and noradrenergic function appear necessary for the clinical efficacy of pharmacological treatments for ADHD, providing support for the hypothesis that alteration of monoaminergic transmission in critical brain regions may be the basis for therapeutic action in ADHD (Berridge et al. 2006). However, as not all individuals with ADHD respond well to stimulants, there are perhaps additional neurotransmitters implicated in the disorder. A review of 50 studies by Spencer et al. (2014) supports the role of glutamate in ADHD. Increases in Glutaminergic metabolites in the anterior cingulate cortex (ACC), prefrontal cortex and striatum in youth with ADHD, normalize with stimulant treatment. Magnetic resonance spectroscopy (MRS) detects these changes.

Environmental Factors

There are periods in development when the brain is exquisitely sensitive to exposure to noxious stimuli that influences neurogenesis and synaptogenesis and functionality of the central nervous system (Knudsen 2004). Prenatal exposure to nicotine (Gatzke-Kopp and Beauchaine 2007), alcohol (Godel et al. 2000), and psychosocial adversity (Counts et al. 2005) all have the potential to alter neuronal synaptogenesis and neurotransmitter development resulting in a phenotypic presentation that mimics ADHD such as impulsivity, motoric hyperactivity (Godel et al. 2000), disorganization and inattention along with learning disabilities. Hence, environmental factors that have the potential to affect brain architecture and neurotransmitter systems are risk factors for ADHD.

Assessment:

Although ADHD is now officially a neurodevelopmental disorder, the use of neuro-diagnostic tools such as single-proton emission computed tomography scans (SPECT) are not traditionally available in clinical practice (Schneider et al. 2014). The diagnosis of ADD/ADHD is primarily clinical. A comprehensive history should be obtained that elicits and explores symptoms that several individuals in the child’s life report (parents, teachers, relatives, peers, neighbors) and the extent to which the symptoms are impairing. In addition, a medical history and work up of medical symptoms if indicated may be necessary, i.e., seizures may mimic inattention/blanking out spells. Rating scales such as the ADHD IV RS or the Vanderbilt (among many others) are effective means of getting standardized information about the child from varying observers but must never be the only data point for making the diagnosis. Psychiatric comorbidity such as a mood disorder and substance abuse in older children should be explored. Continuous performance tests (CPT) should only be used as supplements to the clinical interview and must not replace it. CPT provides the clinician with cross-sectional data but does not provide context for the data, i.e., inattention may be in the clinical range of abnormality but arising from a significant trauma and not ADHD.

A history of academic performance should explore the child’s innate capabilities versus what they are achieving currently; is the underperformance shifting from subject to subject (more consistent with ADHD) versus stable underperformance in one or two arenas (consistent with a learning disability). This will assist in making recommendations to further test for learning disability or try classroom behavioral accommodations and somatic therapies.

Clinicians should be aware of variations in parenting style: a permissive parenting style (Piotrowski et al. 2013) may lead to impairment in behaviors. Often why a child misbehaves in the presence of one adult versus another can be mystifying to the clinician; however, a good clinical interview will reveal information about familial culture, power structure and gender roles. As an example, gender typical roles can lead to differences in behavior. Mothers will traditionally report a tougher time setting limits but their communication style (less authoritarian, more explanation-based commands) assists children in learning problem solving and reasoning while fathers may get better compliance by short authoritarian commands that help children attain quicker behavioral control. Culture may play an important part in how discipline is instituted. In the South Asian culture where mental disabilities are relatively more stigmatized than even the west, adjectives used to describe the behavior are: “naughty” or “spoiled” (overindulged) suggesting that these are behaviors and not disorders and may come from deficiencies in parenting, etc. (Hong 2008; Lee 2008; Lee and Neuharth-Pritchett 2008). This view of dysfunction may delay seeking help. Help seeking is more likely to occur when the behavior impedes academic success, which is relatively strongly emphasized in the Asian culture (Singh 2008). Culturally competent care is delivered when there is an understanding and respect for the healthcare practices, values/beliefs, and needs of a community. When we understand the cultural background of a family and are nonjudgmental about the culturally driven attitudes toward help seeking, then there is an improvement in compliance and outcomes (NIH 2014). Temperamental mismatch between a parent and child or a teacher and child may also produce defiant behavior. It must be differentiated from ADHD related disruptive behavior that occurs across situations regularly but in varying intensities (classroom, home, with relatives, neighborhood, with peers). Familial or environmental chaos can also produce ADHD like symptoms. Although time and resource intensive, when replaced with a consistent, predictable, and orderly life style, this will dissipate disorganized behavior unlike true ADHD, which will persist. This differentiation is essential because of the implications for treatment.

It is extremely important to understand the context of the behaviors, i.e., the role of stressors and life events as they may produce phenotypic expressions of distress that mimic ADHD symptoms (Fisher 1998). However, once removed, the symptoms remit. Ruling out metabolic etiologies such as hyperthyroidism, medication-induced hyperactivity, or subclinical seizures should be part of the initial evaluation (Harber 2000). The role of psychological assessments is hampered by the length of time it takes to complete them. In uncomplicated ADD (i.e., without Learning Disabilities, Sensory Integration Disorder, etc.) a thorough clinical interview can yield adequate data to confirm a diagnosis. However, psychological testing can be helpful when used to support educational interventions and shed light on cognitive styles, deficits, and strengths. Rating scales can be helpful to provide quantifiable data on behavior at baseline and throughout the cycle of treatment. As stated earlier, these rating scales should supplement clinical interview data and not the other way round. Unfortunately, this is becoming a disturbing trend in busy clinical practices. A thorough and detailed assessment is a good investment for both the clinician and the patient.

In summary, an assessment should include a clinical interview that includes a history of presenting problems, temporal chronicling of past and current problems, connection or lack thereof to stressors, familial or environmental chaos, temperamental styles, genetic diathesis, parenting styles, academic performance, comorbid psychiatric or medical diagnoses. As much as feasible multi-informant data, particularly from teachers, is recommended. Supplemental data should include rating scales such as the Vanderbilt or ADHD IV RS or the Conner RS, intelligence and achievement testing when indicated, CPT (if available) and follow up on suspected medical conditions.

Treatment

Treatment of ADD/ADHD is often determined by the degree of impairment that the symptoms produce. Parents seek help for children while adults seek treatment themselves.

A holistic treatment approach is the most successful (Damico and Armstrong 1996).

  • Based on large multisite studies (MTA), it is clear that medications have a significant and superior impact in comparison to placebo and behavioral interventions on the triad of impulsivity, inattention, and hyperactivity (MTA Cooperative Group 2004).

  • Stimulants are the first line treatment of ADHD. The two major stimulant groups are methylphenidate and mixed amphetamine salts, with both immediate and extended release preparations. The goal of therapy is improvement of symptoms with minimal side effects. Narrative feedback from supervising adults should be used to titrate the dose. Side effects such as appetite suppression, irritability or withdrawal, gastritis, and insomnia can be rate limiting in the titration of these medications and lead to the trial of the non-stimulants such as the alpha-2 agonists, atomoxetine, and bupropion. It is common for parents to be concerned that stimulants lead to substance abuse. Stimulants, however, have been shown to reduce the development of drug and alcohol use disorders later in life (Wilens et al. 2002). The most plausible explanation is that stimulants serve to reduce impulsive decision-making and theoretically reduce the possibility of risk taking behaviors such as substance abuse.

  • However, medications may not be effective in addressing the social adjustment issues seen in individuals with ADHD. Behavioral interventions such as Behavior Parent Therapy and Social Skills Training improve a child’s overall functioning and their ability to form positive relationships and negotiate life situations. Behavioral interventions that involve parents, teachers, and care givers assist in altering the structure of a child’s environment, maximizing positive and minimizing negative behaviors (Kaiser et al. 2011).

  • Skills training approaches that target deficits in social, life, and other organizational skills involve providing children directly with small group didactics (Pfiffner et al. 2007) and assist them in practicing those at home/school and social situations.

  • Bibliotherapy is also useful and gives parents and children the tools to use on their own (Forehand et al. 2010).

Cross-cultural studies in ADHD do indicate that ethnic and cultural factors have an important role in causal model of symptoms (medical versus nonmedical), defining severity of the disorder, family, and societal tolerance toward deviance and disciplinary practices, and definitely in threshold for treatment seeking. Culturally, in South Asia, respect for adults, compliant behavior, submissiveness, and academic success are highly valued. Within the Asian diaspora, the presence of ADHD symptoms can become a major source of discomfort. Although the fallout from the behavioral syndrome is enormous, help seeking behavior may not be swift. Several researchers have examined the differences in these variables by studying ethnic minorities who reside in countries other than where they originated from, such as Asians (e.g., Chinese, Indian Gujaratis) in the US or UK (Soorkia et al. 2011). In a study from Goa, India, cc conducted in-depth interviews with 24 parents recruited from a list of children who had been diagnosed with ADHD at a community-based child development center (CDC). The most frequent reasons for consulting the CDC were educational difficulties. Despite having received an ADHD diagnosis and reporting significant adverse impact of the child’s behavior, most parents were reluctant to accept the biomedical explanatory model or even consider their child’s difficulties as an illness. Instead, parents most commonly attributed causality to psychological models, learning and memory difficulties, and to models that emphasized either the volitional or non-volitional nature of the problem, or to attribute blame to self or spouse. Interventions most commonly used were educational and religious; consultation with the CDC was the last resort for many parents.

Malhotra and Shah (Personal Communication, 2015) indicate that children given a diagnosis of ADHD at their clinic in India were commonly referred from school due to scholastic and/or disciplinary problems. Though on detailed history, parents acknowledge that there had been problems related to hyperactivity, inattention, and impulsivity since early childhood, they had no prior knowledge that these problems could be a “psychological illness” or “medical illness” until teachers referred them to a Child Psychiatry Clinic. Also, overall, they would have never considered seeking any kind of help for these problems, considering them as simply problems attributable to lack of motivation of the child, other family members being too liberal or critical, or blaming self or spouse/spouse’s family. The other parent generally shares this perception, albeit reversing the blame. Thus, difficulties encountered in school and complaints from teachers are the main motivating factors for bringing a child to medical attention. In many of the joint families (nuclear and extended family living together) to which several of these children belong, grandparents are either too liberal or too critical, with an opposite pattern in the parent (especially the mother who either tries to discipline or protect the child). Mothers in joint households have major family responsibilities toward which they are expected to devote more time than toward their children. Thus, quality of “grand parenting” plays a major role in the evolution and attitude toward these symptoms.

The barriers that prevent help seeking behavior within families are related to two enormous burdens that exist worldwide but are particularly exaggerated in developing countries: the first of which is stigma associated with psychiatric diagnoses. Stigma is quite common in western culture. One study noted that college students tended to view individuals who claimed that they received help when suffering from depression as more emotionally unstable than those who were depressed but refused to seek treatment (Ben-porath 2002). Examples of stigmatization in India are also quite evident. Malhotra and Shah (Personal Communication, 2015) indicate that once the diagnosis is communicated to the parents, the reactions are varied. There is usually some relief that it is an illness, or complete dismissal of a medical model (though enmeshed in bio-psycho-social model). Most parents are reluctant to start medications and insist on nondrug measures, unless problems are very severe and disruptive especially at school (impending suspension from school).

The second burden stems from the lack of access to somatic therapies, as there is limited availability of pharmacological agents in developing countries. Only small portions of the mental health physicians reside in areas of where over 90 % of the global population lives and the majority of the 400 million people with a mental health disorder are not being treated (Patel et al. 2006). In recent years, referrals from schools have increased in India (Malhotra and Shah, Personal Communication, 2015), which might be reflective of teachers’ increasing sensitivity toward this problem. However, most schools and parents continue to use punitive measures most commonly. Also, most schools do not seem to be equipped with resources to engage such children in more structured environments, though are receptive to professional suggestions.

Medication also has its complications. Specific dose and timing of medication for each child or adult suffering from ADHD must be carefully titrated and monitored until proper dose has been achieved for optimum functioning with minimal side effects (National Resource Center on ADHD 2008). For example, methylphenidate only has a 55 % efficacy when used in low or medium doses (Elia et al. 1991). Additionally, side effects of amphetamines include anorexia, insomnia, irritability, nervousness, and anxiety (Efron et al. 1997), which may lead to noncompliance.

To understand fully the similarities and differences between how ADHD is seen from both an American and Indian psychiatric perspective, we compared the history of present illness from two psychiatrists treating a child with ADHD.

The US Perspective:

John is a 5-year-old Caucasian male who is brought to this evaluation by his parents who have had a third child just recently. John is the middle child.

John did not make it into any of the kindergartens in the private schools in the town and the schools cited immaturity as well as a problem in attention, impulsivity, and inability to deal with prescribed tasks during the screening for kindergarten. Parents are concerned as they have placed several interventions such as occupational therapy and speech therapy, and they have a social coach for him through a private foundation. John has been identified as having problems particularly in the social and emotional arenas as well as motor lags early on in life. He was identified as having these problems through the Early Intervention Services and has received an intervention program through the preschool that he attends. According to parents, he is somewhat delayed in his milestones and he has always been rather distracted. His distractibility as well as impulsive behavior tends to get in the way of his academic achievements and he really has a tough time in-group situations. He does not follow through with instructions in class. Transitions are extremely difficult; 80 % of the time he has difficulty adjusting to the requests which have made by the adults around him. He gets easily frustrated because of that. The other prominent part of his presentation is that if he cannot get his way or feels that he is being pushed in one direction, he will dig his heels in and refuse to respond to the instructions. Examples of these are if he is asked to take a shower or get dressed in the mornings. He will have a major temper tantrum as this would mean that he has to stop whatever he was doing and follow adults’ instructions. Often times, he has a hard time handling social situations such as harassing his 6-year-old sister enough to make her cry. Given that she does respond to him negatively, John is somehow satisfied. Furthermore, his parents note that he takes great pleasure in watching his actions produce a reaction in others. Parents sometimes feel that they have to walk on eggshells simply because they do not know if he will emotionally regress. As far as his inattentiveness and distractibility, parents indicate that he follows through with tasks only halfway and will often be found standing with his pants around his ankles when he has been told to get into his pajamas. He genuinely forgets what the instructions were and at other times they feel that he can be just oppositional. On the positive side, he is seen as being a happy extrovert who has zest for life, and he has a lovely demeanor. He also has a good appetite. He sleeps well and is generally described as someone with a happy mood. Often times he tends to wake up early in the morning. They have noted phases of constipation. He has been identified as having a sensory processing problem, the sensory seeking issues have to do with hyperacusis, running into people and clinging to them in a socially inappropriate fashion. He is a tactile child who likes to “horse play” and then does not know how to stop that behavior, ending up in tackling other children leading to social ostracism. Psycho-educational testing shows functioning in the low average range of IQ.

In summary, the problems appear to be present despite the fact that several services through early intervention have been put into place, but he has trouble with distractibility and impulsive behavior. This is functionally impairing his ability to learn and progress Parents are ready to try medications.

3 The South Asian/Indian Perspective

An 8-year-old boy Ganesh, from a Hindu joint family of middle socioeconomic background was brought to the clinic as a referral from school. Ganesh’s father ran a family business and mother was a homemaker. Ganesh’s grandparents and a younger paternal uncle and his family resided in the same household. His mother and his paternal aunt had to take turns in carrying out various household chores (as decided by grandfather). When mother would have to cook the evening dinner for the whole family, she would not find any time to spend with Ganesh. He was the first male child in the family and was pampered by the grandparents.

The school teachers repeatedly complained to the parents during parent–teacher meeting that Ganesh just did not obey them, seemed very disinterested in his studies, would often not complete his work, make careless mistakes (“but of course, at times he does his work alright”), did not sit at one place, was extremely naughty, would keep fiddling with other children’s belongings. Ganesh would very often leave the classroom without permission. They advised the parents that a child psychiatrist or a counselor should see him. Parents had earlier received similar complaints from the previous school. At home, Mother faced difficulties in even dressing him, feeding him, making him sit to study. She felt “I’m always running after him. If I don’t keep an eye on him for a minute, something would happen…he might fall or break something.” She found it more difficult to care for him since the birth of his younger sister (for last 4 years). She would often lose her temper with Ganesh and beat him for which she was severely criticized by her father-in-law. Ganesh’s father would return home only at night and would usually ignore the child’s behavior, but occasionally suddenly get very angry and beat him. Grandfather maintained that he was a little naughty and parents were overreacting. In fact, when they received complaints from the previous school, he advised them to change the school. Three years have passed since the first complaint from school. This time around, the parents brought the child to us without the knowledge of the grandparents. After detailed history and examination/observation, when the parents were told that Ganesh is most likely suffering from a medical disorder ADHD and that even his apparent disobedience is stemming from that, they were surprised. They immediately requested the doctors to counsel Ganesh “to behave well.” When pharmacological options were given, they were extremely reluctant and chose to go ahead with counseling.

By comparing both histories side by side, we see several differences emerge. Initially, it can be noted that both John and Ganesh demonstrate hyperactive and impulsive behavior, which is evident in both their classroom and home environment. However, Ganesh’s parents took much longer to seek treatment and once evaluated, emphasized his inability to perform in school (via feedback from his teachers) as a critical flaw. This point was not nearly as emphasized in John’s history, which focused more on his social interactions with his peers and family as deficits in his behavior. Access to care is also a major difference seen between both cases. John has had speech therapy, occupational therapy, and social coaching prior to his initial assessment by a psychiatrist. However, both teachers and parents have only counseled Ganesh prior to his assessment. While access to different behavioral counseling techniques may have been available in the area, the parents did not know what therapy was available. Grandparental influence on “normalizing the behavior” is seen not only in South Asian cultures but in the West too but the eastern culture is more permissive in allowing that to be the decision-making voice rather than the parents. This is secondary to the deference given to the “elders” within Southeast Asian cultures (Singh 2008). Hence, conceptualization of dysfunctional behavior, threshold for seeking help, the type of help utilized and the lag time between diagnosis and treatment may be quite different from a cultural standpoint.

An awareness of these differences and similarities across continents is helpful as we embark on the new era of using the revised/new criteria per the DSM-5 to diagnose ADHD. Whether these changes that have placed ADHD as a neurobiological disorder while simultaneously broadening diagnostic criteria will serve the field well will be evident from prospective design studies that determine how well these criteria capture the construct of the disorder, how stable is the diagnosis over time, what predictive validity do these criteria have, and whether they are better able to assist the practitioner in the field. Future studies that provide a head-to-head comparison of psychopathology in countries in the Western and the Eastern hemispheres, i.e., culturally dissimilar but using similar classification systems, would be helpful in order to constantly, consistently, and thoughtfully refine the DSM for the betterment of children and adults who suffer from mental disorders like ADHD.