Cultural factors in the diagnosis and treatment of children and adolescents. M Maldonado, K Pope, C Millhuff

Transcription

1 Cultural factors in the diagnosis and treatment of children and adolescents M Maldonado, K Pope, C Millhuff

2 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

3 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

4 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

5 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?

6 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

7 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

8 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?

9 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?

10 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, McArdle et al, 1995 #Swanson et al, 1998

11 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)

12 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

13 Factors in prevalence Stress during pregnancy? Effects of day care setting and quality of day care? Cultural expectations?

14 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

15 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

16 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

17 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

18 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)

19 Conceptualization of disorder determines intervention Biological models require biological interventions: Medications Strategies to regulate the brain (e.g. occupational therapy, biofeedback, vitamines, supplements, etc.)

20 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?

21 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

22 Psychotropic medications

23 Acculturation and transculturation Healthy immigrant phenomenon Found for several medical and psychiatric conditions With acculturation there may be some negative consequences

24 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

25 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.

26 Acculturation adolescents Risk factors: More time watching television Less time spent in family activities Less involvement with friends Less involvement in sports

27 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