1. INTRODUCTION
Attention deficit/hyperactivity disorder (ADHD) is a life span neurodevelopmental disorder characterized by age inappropriate and impairing levels of inattention and/or hyperactivity/impulsivity (American Psychiatric Association, 2013; Posner et al., 2020). Interestingly, global comparisons of epidemiological studies have found little evidence that the prevalence of ADHD varies between nations and/or cultural and ethnic groups, once methodological variations are accounted for; the best global estimate for child ADHD being around 5% (Polanczyk et al., 2007, 2015). In this paper we explore the possibility that these cross‐regional similarities in ADHD prevalence mask cross‐region differences in actual ADHD related‐behaviours. This possibility stems from the fact that decisions to diagnose an individual depend on the subjective reports and interpretations of adults (i.e., parents and teachers) filtered through the prism of clinical judgement: The key question being “Is a child’s ADHD behaviour displayed to a sufficient degree to cross the threshold for it to be endorsed as a symptom” (Canino & Alegria, 2008; MacDonald et al., 2019; Reid & Maag, 1994). This of course means that factors that change the endorsement threshold will affect whether a behaviour is considered a symptom. Some factors are linked to child characteristics such as sex (Meyer et al., 2020) or ethnicity (Sonuga‐Barke et al., 1993). Others are linked to informant characteristics such as mental health (De Los Reyes & Kazdin, 2005; Najman et al., 2001), parenting style (Bajeux et al., 2018; Luk et al., 2002) and/or values (Gross et al., 2004). Still others may derive from family factors (Stone et al., 2013). In the threshold model, Weisz et al. (1988) proposed that cultural differences in levels of parental distress over a child’s troubling behaviours—associated with social norms regarding children’s conduct and child‐rearing practices—will also impact these thresholds (Canino & Alegria, 2008; Gomez & Vance, 2008; Hillemeier et al., 2007; Porter et al., 2005; Thompson et al., 2017; Weisz et al., 1988).
On this basis it can be hypothesized that cultural variations in endorsement thresholds for ADHD‐related behaviours could lead to the same symptom ratings being associated with different levels of actual behaviour. Here we test this possibility by studying endorsement thresholds in two nations, the UK and HK. To do this we compared the levels of directly measured child activity associated with UK and HK parent’s ratings of hyperactivity/impulsivity and inattention symptoms. We then explored the cultural differences in some parenting‐related factors that might explain any regional rating threshold differences found. We chose these two nations because, although they are reported to have a similar prevalence of ADHD (Child Assessment Service Department of Health, HKSAR, 2007; Leung et al., 2008; NICE, 2000), parenting research suggests that they have different cultural views about how children should behave, which may be reflected in their ADHD rating thresholds. For instance, it has been repeatedly noted that HK parents, compared to western parents, have relatively high expectations for their children’s behaviours when it comes to conformity to rules (Chao, 1994; Chen, 2005; Lam & Ho, 2010; Thompson et al., 2017). In Chinese culture, social norms require individuals to exercise self‐control and compliance to avoid creating trouble or inconvenience for others (Chao, 1995). Parents of children who behave in ways that breach these standards may experience higher level of parenting stress (Leung et al., 2005). In western culture, parents are more likely to adopt a more child‐centered approach, with more freedom given to children to exercise their “energy” (Chen et al., 2003). We hypothesize that this general approach to parenting and attitudes to children, and the stress that occurs where children do not conform, will be associated with a lower threshold for ADHD‐behaviours in HK compared to UK parents.
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Previous studies provide indirect evidence that HK parents rate their children as having more ADHD symptoms than UK parents. Ho et al. (1996) found that HK boys were rated as having twice the levels of ADHD symptoms compared to UK children on Rutter’s questionnaires items—“restless”, “fidgety”, “can’t settle” (Rutter et al., 1970). A more recent study found similar results for teacher ratings (Lai et al., 2010; Meltzer et al., 2000).
Despite these rating scale findings, studies of actual behaviour tend to suggest that HK children are less active than their UK counterparts. For instance, Luk et al. (2002) compared a HK epidemiological study of hyperactivity (Leung et al., 1996) against a separate but similar British study (Taylor et al., 1991) and found that the measured activity level was significantly lower in HK than UK children. Conformity and self‐control are highly valued by parents in HK culture (Chao, 1994; Chen, 2005; Lam & Ho, 2010; Thompson et al., 2017), we therefore predicted that parents in HK would be especially sensitive to more deviant hyperactive behaviours (Ho et al., 1996).
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Although these initial studies are consistent with the hypothesis of cross‐national differences in ADHD rating thresholds, they have limitations. The comparisons across cultures were not direct, relying instead on data that were collected at different times and often for different purposes, creating potentially important methodological inconsistencies. Furthermore, the cultural differences in the relationship between informant ratings and measured activity were usually addressed separately, with no recent studies examining the two constructs concurrently. Finally, there was no attempt to explore what might underlie these cultural differences in rating thresholds: Are they, as suggested by the Weisz et al. (1988) model, mediated by differences in parenting attitudes, values and tolerances? In the current study we addressed these limitations by applying a common protocol to collect data in the UK and HK, with informant ratings of ADHD symptoms and actual activity collected for the same children using the same approach. We then explored whether the differences found could be explained by cross‐national differences in general parenting attitudes and reactions to their children in terms of ADHD‐specific emotional responses and more general child related stress.
We addressed four research questions; (i) Do UK and HK parents differ in their ADHD rating thresholds as reflected in the relationship between their ratings of ADHD symptoms and their children’s actual behaviour? (ii) Are these effects different for children with high and low levels of rated ADHD? (iii) Do UK and HK parents differ in their parenting attitudes, parenting stress and emotional reactions to ADHD symptoms? (iv) Do such cultural differences in parental characteristics mediate the national differences in ADHD rating thresholds? Based on prior studies, we hypothesized that; (i) UK children would be more active than HK children who have the same level of parent‐rated hyperactivity/impulsivity symptoms; (ii) this national difference in activity level would be more marked in children rated high for ADHD, suggesting that HK parents ratings are particularly sensitive to severe ADHD symptoms; (iii) HK parents would have more authoritarian parenting attitudes, experience more parenting stress and have stronger emotional reactions to ADHD symptoms; (iv) these cultural differences in parental characteristics would statistically explain the relationship between national groups and rating thresholds.
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