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1 / Journal Norvilitis, of Attention Fang / Perceptions Disorders of / November ADHD 2005 Perceptions of ADHD in China and the United States: A Preliminary Study Journal of Attention Disorders Volume 9 Number 2 November Sage Publications / hosted at Jill M. Norvilitis State University of New York College at Buffalo Ping Fang Capital Normal University, Beijing College students (n = 226) and teachers (n = 328) in the United States and China completed a 55-item questionnaire examining perceptions of attention deficit/hyperactivity disorder (ADHD) in the two countries. Although a factor analysis yielded somewhat similar structures for the construct of ADHD, many differences emerged as well, with Chinese participants somewhat more attuned to hyperactivity than inattention. Furthermore, presented with a list of potential perceptions of ADHD, there were significant differences by culture in agreement with most of those statements. Thus, it appears that the concept of ADHD may be similar between the cultures, but the many differences warrant further exploration before ADHD is considered to be equivalent in the two countries. (J. of Att. Dis. 2005;9(2), ) Keywords: attention deficit/hyperactivity disorder; China; perceptions Children in the United States with attention deficit/ hyperactivity disorder (ADHD) face a difficult childhood. Such children demonstrate inattention, impulsivity, and hyperactivity. Although it used to be assumed that the 3% to 5% of children with ADHD would simply outgrow it, evidence now suggests that as many as 70% of these children will continue to experience difficulties as adolescents, and many of these will suffer as adults (Goldstein, 1996). At present, it is unclear whether all the characteristics of the disorder are universal or culture specific. One culture lacking cross-cultural comparisons of this disorder is China. Previous cross-cultural work on ADHD in China has focused on a few primary questions: whether Western scales can be reliably used in China; the prevalence of ADHD in China (Ho et al., 1996; Mann et al., 1992), particularly the hyperactivity dimension; and comorbidity with other diagnoses (e.g., Leung, Luk, et al., 1996). However, we argue that these questions, though important, should be secondary to one that has received less attention: whether the construct of ADHD itself is comparable in China and other countries. Several Western scales have been translated for use in Mainland China, Hong Kong, and Taiwan. These include the Achenbach Child Behavior Checklist (CBCL) and Teacher Rating Form (TRF; Liu et al., 2000, Li, Su, Townes, & Varley, 1989), the Conners Teacher Rating Scale (CTRS; Luk & Leung, 1989; Luk, Leung, & Lee, 1988; Yang & Schaller, 1997), and the Rutter s Teacher and Parent Scales (Ho et al., 1996; Leung, Luk, et al., 1996). Although the scales have generally been supported, some limitations have emerged. Li and colleagues (1989) reported that the CBCL and TRF were able to distinguish between children with and without ADHD in Mainland China. However, use of the U.S. norms and the recommended T score cutoff of 70 would yield a 50% to 60% false negative rate, suggesting that there are differences in diagnosis of ADHD between the two cultures. Similarly, in their investigation of the reliability and validity of the TRF, Liu et al. (2000) suggested using the 90th percentile Authors Note: This research was supported through a State University of New York Research Foundation Incentive Grant. A portion of this research was presented at the annual convention of the American Psychological Association, Toronto, Canada, August Address correspondence to Jill M. Norvilitis, Department of Psychology, State University of New York College at Buffalo, Buffalo, NY 14222; 413

2 414 Journal of Attention Disorders / November 2005 (T score 62) as the threshold for impairment in China, as opposed to the 98th percentile (T score 70) used in the United States. Thus, in both cases, Chinese children with ADHD were reported to have lower levels of impairment than Western children. Li and colleagues hypothesized that this is due to increased family stability in China, but other possibilities include the response set used by the raters and how ADHD itself is viewed. That is, perhaps raters in China have a different standard for what is considered a severe impairment. The CTRS has also been found to reliably distinguish between comparison and behaviorally deviant children in Hong Kong; however, it, too, had high rates of false positives and negatives (Luk & Leung, 1989). In contrast to Liu et al. (2000) and Li et al. (1989), Luk and colleagues (1988) found unexpectedly high scores on the hyperactivity, conduct, and inattention dimensions of the CTRS compared to Western cultures. Luk and Leung (1989) suggested that the scale may provide useful information and be beneficial for cross-cultural comparison but should not be relied upon for diagnosis. Despite the limitations of these measures in Chinese culture, they and others have been used to explore the nature of ADHD. However, among the studies that have been done, many questions remain. First, the nature and level of the hyperactivity dimension is unclear. Ho and colleagues (1996), in a study of Hong Kong Chinese, found that Chinese boys were reported to show twice the level of hyperactivity as boys in the West, in agreement with the work of Luk et al (1988). However, Mann and colleagues (1992) reported that Chinese mental health professionals may have a lower threshold for rating behavior as hyperactive than professionals in the United States, potentially explaining this result. Furthermore, research with Taiwanese teachers found that they are unlikely to refer children with ADHD for services unless their hyperactivity reaches three standard deviations above the mean (Yang & Schaller, 1997). This may artificially raise the hyperactivity scores of groups of children with ADHD because only the most seriously impaired children are referred. Thus, there may be differences in both the threshold for what is hyperactive and in the threshold for referral. Clearly, the severity findings are mixed, with some showing less impairment and others showing more impairment in Chinese children with ADHD, an issue that needs further research. It is also unclear from the present literature if attention deficits are as prominent in the diagnosis of ADHD in China as such deficits are in the United States. Several Chinese studies focus on hyperactivity and appear to view attention deficits as secondary. For example, Leung and Connelly (1996) used a pure hyperactive group and noted that such children are often said to be inattentive and distractible (p. 305), suggesting, by the very name of the diagnosis, that hyperactivity is the primary problem and inattention is less critical. In their study of behavioral disturbances, Ho and colleagues (1996) assessed hyperactivity, antisocial, and neurotic behaviors but did not address inattention. Leung, Ho, et al. (1996) similarly did not target inattention. No study located to date has done the opposite, that is, specifically examined perceptions of inattention while not assessing hyperactivity. Although this may be a result of differing terminology for what is now known as ADHD, it also indicates the focus of diagnosis. This may indicate that hyperactivity is the more prominent dimension in China. Still another issue in the diagnosis of ADHD is whether the concept is more broad or incorporates more symptoms in one culture or the other. Tao (1992) argued that the definition of ADHD appears to be more inclusive in China, but others report prevalence rates of 3% to 7% (Leung, Luk, et al., 1996; Yu-cun, Yu-feng, & Xiao-Ling, 1985), which are similar to those found in the United States. To more directly assess the factor structure of the diagnosis, Yang, Schaller, and Parker (2000) presented Taiwanese teachers with 20 ADHD symptoms upon which to rate randomly selected children. Factor analysis indicated a similar structure to that found in the United States, with hyperactivity and impulsivity loading onto one factor and inattention onto another. No additional symptoms, such as conduct disorder behaviors, were assessed as part of the factor analysis. Furthermore, less direct evidence of similarity between the two cultures is that ADHD is more prevalent in boys than girls (Salili & Hoosain, 1985) and that EEGs show similar patterns among those diagnosed with ADHD (Matsuura et al., 1993) in both cultures. A final issue is that several of the studies above were conducted in either Taiwan or Hong Kong. Alban- Metcalfe, Cheng-Lai, and Ma (2002) compared the assessment of ADHD in Mainland China, Hong Kong, and the United Kingdom by showing teachers a videotaped target child. They reported that in a number of cases, teachers in Mainland China rated the behavior shown as more hyperactive, inattentive, and impulsive than the Hong Kong or U.K. teachers. This indicates that people in Mainland China may have different views about ADHD than other Chinese populations. Thus, although ADHD appears to be similar in China and the United States, important issues remain. Specifi-

3 Norvilitis, Fang / Perceptions of ADHD 415 cally, whether the hyperactivity and inattention dimensions are viewed similarly and whether more symptoms are included in one culture than the other need to be addressed. Furthermore, ADHD does not occur in a vacuum. It is important to know how people view the diagnosis to better understand who is being referred for assessment and what impediments might stand in the way of diagnosis and treatment. Therefore, the present study examined perceptions of ADHD among college students and teachers in the United States and China. Teachers were selected because they are the front line for recognition and referral of children with difficulties, and college students were selected because they represent a cross-section of society that is not trained to recognize or diagnose ADHD. Thus, college students perceptions should reflect that of the general public. Both groups were asked about their perceptions of the disorder, what symptoms they found most critical to diagnosis, and the age at which one should first consider diagnosis. It was expected that the Chinese sample would weigh hyperactivity symptoms more heavily than the American samples, which would incorporate both inattention and hyperactivity. The remainder of the study was considered exploratory, with no specific hypotheses. Because the two samples are distinct, the teachers results are presented first, followed by the students results. Method Study 1 Participants Teachers were recruited through participating schools in a variety of urban and suburban districts and from every grade level from kindergarten through 12th grade. Three hundred twenty-eight teachers participated. Of these, 202 (62%) were from China and 126 (38%) were from the United States. Of the Chinese sample, 102 (51%) were elementary school teachers and 100 (50%) were middle and high school teachers. Of the American sample, 71 (56%) were elementary school teachers and 55 (44%) were middle and high school teachers (χ 2 = 1.07, p >.05). There were 99 males, with more males in the Chinese (n = 71, 35%) than the United States sample (n = 29, 23%; χ 2 = 5.88, p <.05). The average age was (SD = 6.78; American M = 34.86, SD = 10.48; Chinese M = 33.39, SD = 6.04) and there was no significant age difference between the samples, t(297) = 1.59, p =.11. Of the American sample, 117 (94%) were Caucasian, 5 (2%) were African American, 2 (1%) were Hispanic, 1 (<1%) was Native American, and 1 (<1%) decline to identify ethnicity. All of the Chinese sample were ethnic Chinese. Although the teachers education levels were not obtained in this study, a minimum of a bachelor s degree is required to teach in both settings, thus ensuring comparability of educational backgrounds between samples. Materials and procedure Prior to administration of the study, the measure was translated into Chinese and then back-translated into English by a second bilingual person with a master s in linguistics to ensure the equivalence of the measure in the two cultures. Participating schools were recruited from a variety of urban and suburban areas to ensure a broad representation. Following written consent, teachers in the participating schools completed a 55-item questionnaire created for this study. Thirty items were symptoms of ADHD and related behaviors (see Tables 1 and 2). Participants were asked to what degree they believed that each was important to diagnosis, on a scale of 1 (a hallmark of ADHD) to 7 (not part of ADHD). The items were based upon the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision; DSM-IV-TR) criteria for ADHD and Oppositional Defiant Disorder (American Psychiatric Association, 2000). Some items are symptoms listed in the DSM-IV-TR; others reflect symptomatology that is not listed in the DSM-IV-TR (e.g., Having concentration problems ). An additional 5 questions asked about related behaviors, such as performing poorly in school and having poor peer relationships. One question asked the age at which one should first consider diagnosing ADHD. An additional 21 items explored beliefs about ADHD (see Table 3). Participants were asked to rate the beliefs on a 5-point scale from 1 (strongly agree) to 5 (strongly disagree). The first 12 items were developed for use by Norvilitis, Scime, and Lee (2002) in their study of courtesy stigma associated with ADHD in the United States. The authors reported that the scale was reliably used to indicate differences in how parents of children with and without ADHD view the disorder. The items were designed to reflect both positive and negative views of the diagnosis, and each received a broad range or responses. The additional 9 items were developed by the authors to include items about prognosis, medication, and the role of parents and the school in helping children with ADHD. The remaining items were demographic.

4 416 Journal of Attention Disorders / November 2005 Table 1 Rankings of Importance of Symptoms Among American and Chinese Samples American American Chinese Chinese Teachers Students Teachers Students Having concentration problems Having difficulty sustaining one s attention in tasks or fun activities Being easily distracted Losing control of oneself Acting without thinking Having difficulty organizing tasks or activities Engaging in reckless activities without considering the consequences Being impulsive Avoiding, disliking or being reluctant to engage in work that requires sustained mental effort Feeling on the go or driven by a motor Not listening when spoken to directly Fidgeting with hands or feet or squirming in one s seat Leaving one s seat in situations in which seating is expected Having difficulty waiting turns Feeling restless Not following through on instructions Failing to finish work Interrupting or intruding on others Blurting out answers before questions have been completed Losing things necessary for tasks or activities Performing poorly in school Being forgetful in daily activities Failing to give close attention to details or making careless mistakes in one s work Having difficulty engaging in leisure activities or doing fun things quietly Talking excessively Daydreaming Completing sloppy work Having poor peer relationships Talking back to parents, teachers, or other adults Having a comorbid diagnosis of depression Results Symptoms of ADHD The means for the 30 items were ranked within country (see Table 1). The five most important symptoms according to the Chinese teachers, with their American rankings in parentheses, were, in order, Losing control of oneself (4); Having concentration problems (1); Feeling restless (15); Fidgeting with hands or feet or squirming in one s seat (12); and Having difficulty engaging in leisure activities or doing fun activities quietly (24). Of the top 10 most important symptoms to the diagnosis of ADHD, 6 were hyperactive/impulsive and 4 were inattentive. The 5 most important symptoms according to the American teachers, with their Chinese rankings in parentheses, were, Having concentration problems (2); Having difficulty sustaining one s attention in tasks or fun activities (7); Being easily distracted (8); Losing control of oneself (1); and Acting without thinking (17). Of the top 10 most important symptoms to the diagnosis of ADHD, 5 were hyperactive/impulsive and 5 were inattentive. To further explore the similarity with which Chinese and American teachers view the critical symptoms of ADHD, a factor analysis of the mean importance scores was completed. It was not expected that such a factor analysis would identify the structure of ADHD (that is, the hyperactivity and inattention dimensions) but rather that clusters of the symptoms most important to diagnosis in both cultures would emerge. Principal components factor analysis with varimax rotation indicated somewhat

5 Norvilitis, Fang / Perceptions of ADHD 417 Table 2 Factor Loadings of ADHD Symptoms and Related Characteristics for American Teachers Factor 1, Factor 2, Factor 3, Factor 4, Factor 5 17% Var 16% Var 13% Var 10% Var 7% Var Having difficulty waiting turns Being forgetful in daily activities.70 Interrupting or intruding on others.61 Not following through on instructions Failing to finish work Having difficulty organizing tasks or activities Completing sloppy work Avoiding, disliking, or being reluctant to engage in work that requires sustained mental effort Talking excessively.66 Losing things necessary for tasks or activities.77 Blurting out answers before questions have been completed.73 Fidgeting with hands or feet or squirming in one s seat Having difficulty sustaining one s attention in tasks or fun activities.70 Leaving one s seat in situations in which seating is expected Not listening when spoken to directly Feeling restless Having difficulty engaging in leisure activities or doing fun things quietly Having concentration problems.84 Feeling on the go or driven by a motor Being easily distracted.73 Engaging in reckless activities without considering the consequences Performing poorly in school.58 Having poor peer relationships.64 Having a comorbid diagnosis of depression.72 Talking back to parents, teachers, or other adults.58 Failing to give close attention to details or making careless mistakes in one s work.76 Being impulsive.77 Daydreaming.51 Acting without thinking.57 Losing control of oneself.55 Note: Principal components factor analysis with varimax rotation was completed. In the interest of clarity, only factor loadings of.40 or greater are included. Var = variance accounted for. similar factor structures, with five factors for the United States and six factors for China (see Tables 2 and 3). Upon closer examination of the primary factors in the two cultures, one can see that, among the 11 items loading on Factor 1 for the American sample, 4 are hyperactive/ impulsive symptoms, 6 are inattentive, and 1 is not part of the DSM-IV-TR diagnostic criteria ( Completing sloppy work ). For the Chinese sample, among the 11 items loading on Factor 1, 5 are hyperactive/impulsive symptoms, 4 are inattentive, 1 is a characteristic of Oppositional Defiant Disorder ( Talking back to parents, teachers, or other adults ), and 1 is not part of the DSM-IV-TR diagnostic criteria ( Completing sloppy work ). Age of diagnosis The average age at which Chinese teachers would first consider a diagnosis of ADHD was 4.73 (SD = 1.68), which was significantly younger than American teachers would first consider diagnosis (American M = 6.64, SD = 1.93), t(324) = 9.42, p <.001. Perceptions of ADHD Because initial analyses indicated significant differences in variance between samples, the 21 items covering perceptions of ADHD were recoded into agree, neutral, and disagree. Chi-square analyses were completed for

6 418 Journal of Attention Disorders / November 2005 Table 3 Factor Loadings of ADHD Symptoms and Related Characteristics for Chinese Teachers Factor 1, Factor 2, Factor 3, Factor 4, Factor 5, Factor 6, 15% Var 8% Var 8% Var 8% Var 8% Var 8% Var Having difficulty waiting turns.62 Being forgetful in daily activities Interrupting or intruding on others Not following through on instructions.52 Failing to finish work.50 Having difficulty organizing tasks or activities.51 Completing sloppy work.56 Avoiding, disliking, or being reluctant to engage in work that requires sustained mental effort.57 Talking excessively.57 Losing things necessary for tasks or activities Blurting out answers before questions have been completed.65 Fidgeting with hands or feet or squirming in one s seat Having difficulty sustaining one s attention in tasks or fun activities.74 Leaving one s seat in situations in which seating is expected.75 Not listening when spoken to directly.47 Feeling restless.75 Having difficulty engaging in leisure activities or doing fun things quietly.49 Having concentration problems.54 Feeling on the go or driven by a motor.72 Being easily distracted Engaging in reckless activities without considering the consequences.49 Performing poorly in school.44 Having poor peer relationships.59 Having a comorbid diagnosis of depression.79 Talking back to parents, teachers, or other adults Failing to give close attention to details or making careless mistakes in one s work.77 Being impulsive.76 Daydreaming.50 Acting without thinking.56 Losing control of oneself Note: Principal components factor analysis with varimax rotation was completed. In the interest of clarity, only factor loadings.40 or greater are listed. Var = variance accounted for. each item. This appears to be a true difference in response style rather than an artifact of switching from a 7-option response format for the first 30 items to a 5-option response format for the 21 perception items because, among all of the items for both groups of participants, there was only 1 response (of the 6,867 generated) that was either missing or out of range. There were significant differences between groups for every one of the 21 items. For example, on the item, Children with ADHD are just bored and need more to do, 71% of Chinese agreed with this statement, and 72% of Americans disagreed with it, χ 2 (2, 1) = , p <.001. The smallest difference was found on the item, ADHD is a result of spoiling the child, for which 63% of Chinese and 75% of Americans disagreed, χ 2 (2, 1) = 6.03, p <.05. See Table 4 for the results for all of the items. Method Study 2 Participants Two-hundred twenty-six college students participated. Of these, 116 (52%) were from China and 108 (48%) were from the United States. There were 40 males with more males in the Chinese (n = 26, 22%) than the United States sample (n = 14, 13%), although this difference was

7 Norvilitis, Fang / Perceptions of ADHD 419 Table 4 Perceptions of ADHD in the Two Samples of Teachers American Chinese Agree Disagree Agree Disagree n (%) n (%) n (%) n (%) ADHD is overdiagnosed today. 103 (82) 6 (5) 38 (19) 103 (51)*** ADHD is underdiagnosed today. 4 (3) 97 (77) 116 (57) 28 (14)*** Medication for ADHD should be used only as a last resort. 80 (64) 21 (17) 19 (9) 130 (64)*** Most children with ADHD just need more discipline. 30 (24) 60 (48) 128 (63) 36 (18)*** Schools do not offer enough support services for children with ADHD. 56 (45) 36 (29) 114 (56) 57 (28)* Most children with ADHD don t try hard enough to help themselves. 15 (46) 75 (60) 134 (66) 30 (15)*** Teachers are supportive of children with ADHD. 50 (40) 34 (27) 149 (74) 17 (8)*** ADHD is often diagnosed by unqualified individuals. 44 (35) 33 (26) 84 (42) 75 (37)** ADHD is biologically based. 60 (48) 14 (11) 122 (60) 25 (12)* Most children with ADHD are just as smart as other kids. 111 (89) 4 (3) 142 (70) 23 (11)*** ADHD children are more likely to be troublemakers than other children. 56 (45) 40 (32) 145 (72) 26 (13)*** You can often tell if a child has ADHD by looking at the way their parents act toward the child you don t always have to see the child to know. 13 (10) 91 (73) 58 (29) 70 (35)*** Medication should be used as a first line treatment for ADHD. 2 (2) 107 (86) 42 (21) 99 (49)*** Parents of children with ADHD just don t know how to control their children. 14 (11) 80 (64) 118 (58) 47 (23)*** Almost all children with ADHD with outgrow it by their teens. 13 (10) 73 (58) 40 (20) 69 (34)*** Almost all children with ADHD will outgrow it by their early twenties. 25 (20) 62 (50) 62 (31) 49 (24)*** It is an embarrassment to the family to have a child with ADHD. 12 (10) 80 (64) 67 (33) 107 (53)*** ADHD is a result of spoiling the child. 10 (8) 94 (75) 31 (15) 127 (63)*** It is the schools job to instill discipline for ADHD children when the parents have failed. 17 (14) 77 (62) 91 (45) 79 (39)* Children with ADHD are just bored and need more to do. 13 (10) 90 (72) 143 (71) 25 (12)*** Children with ADHD are more creative than other children. 20 (16) 41 (33) 66 (33) 46 (23)** Note: To enhance the clarity of the table, only agree and disagree responses are listed here. The remainder of the 328 participants were neutral. *p <.05. **p <.01. ***p <.001. not significant (χ 2 = 3.41, p =.07). The average age was (SD = 4.44; American M = 22.75, SD = 7.14; Chinese M = 21.41, SD = 1.13), and there was no significant age difference between the samples, t(181) = 1.97, p =.13). Of the American sample, 86 (80%) were Caucasian, 13 (12%) were African American, 6 (6%) were Hispanic, 2 (2%) were Native American, and 1 (1%) was Asian American. All in the Chinese sample were ethnic Chinese. Materials and procedure College students were recruited to participate from psychology courses in two comparable universities in China and the United States. The universities are of comparable size, both are located in urban areas, and both focus heavily on teacher education. All students gave written consent and completed the same questionnaire as the teachers. Results Symptoms of ADHD The means for the 30 items were ranked within country (see Table 1). The five most important symptoms according to the Chinese students, with their American rankings in parentheses, were, in order, Having concentration problems (1); Losing control of oneself (6); Being easily distracted (2); Having difficulty sustaining attention in leisure activities or fun activities (3); and Fidgeting with hands or feet or squirming in one s seat (8). Of the top 10 most important symptoms to the diagnosis of ADHD, 6 were hyperactive/impulsive and 4 were inattentive. The five most important symptoms according to the American college students, with their Chinese rankings in parentheses, were, Having concentration problems (1); Being easily distracted (3); Having difficulty sustaining one s attention in tasks or fun activities (4); Having

8 420 Journal of Attention Disorders / November 2005 Table 5 Factor Loadings of ADHD Symptoms and Related Characteristics for American College Students Factor 1, Factor 2, Factor 3, Factor 4, Factor 5, Factor 6, Factor 7, 15% Var 15% Var 12% Var 7% Var 6% Var 6% Var 6% Var Fidgeting with hands or feet or squirming in one s seat.46 Having difficulty sustaining one s attention in tasks or fun activities.71 Feeling restless Not following through on instructions Failing to finish work Having difficulty engaging in leisure activities or doing fun things quietly.59 Having concentration problems.85 Having difficulty organizing tasks or activities.59 Avoiding, disliking, or being reluctant to engage in work that requires sustained mental effort Being easily distracted.75 Having difficulty waiting turns Interrupting or intruding on others Talking back to parents, teachers, or other adults Completing sloppy work.58 Talking excessively.60 Losing things necessary for tasks or activities.81 Blurting out answers before questions have been completed.65 Being forgetful in daily activities.77 Engaging in reckless activities without considering the consequences.50 Having poor peer relations.68 Not listening when spoken to directly.66 Having a comorbid diagnosis of depression.70 Acting without thinking.45 Failing to give close attention to details or making careless mistakes in one s work.79 Being impulsive.77 Losing control of oneself.64 Feeling on the go or driven by a motor.83 Performing poorly in school.77 Leaving one s seat in situations in which seating is expected.49 Daydreaming a Note: Principal components factor analysis with varimax rotation was completed. In the interest of clarity, only factor loadings of.40 or greater are included. Var = variance accounted for. a. This item did not load on any factor. difficulty waiting turns (11.5); and Avoiding, disliking, or being reluctant to engage in work that requires sustained mental effort (17). Of the top 10 most important symptoms to the diagnosis of ADHD, 5 were hyperactive/ impulsive and 5 were inattentive. Principal components factor analysis with varimax rotation indicated somewhat less similar factor structures than found in Study 1, with seven factors for the United States and eight factors for China (see Tables 5 and 6). Upon closer examination of the primary factors in the two cultures, one can see that, among the 12 items loading on Factor 1 for the American sample, 5 are hyperactive/ impulsive symptoms and 7 are inattentive. For the Chinese sample, among the 6 items loading on Factor 1, 4 are hyperactive/impulsive symptoms and 2 are inattentive. Age of diagnosis The average age at which Chinese college students would first consider a diagnosis of ADHD was 4.78 (SD = 1.41), which was significantly younger than American college students would first consider diagnosis, American M = 5.69, SD = 1.85; t(222) = 4.17, p <.001.

9 Norvilitis, Fang / Perceptions of ADHD 421 Table 6 Factor Loadings of ADHD Symptoms and Related Characteristics for Chinese College Students Factor 1, Factor 2, Factor 3, Factor 4, Factor 5, Factor 6, Factor 7, Factor 8, 11% Var 10% Var 9% Var 7% Var 7% Var 7% Var 7% Var 5% Var Fidgeting with hands or feet or squirming in one s seat.80 Having difficulty sustaining one s attention in tasks or fun activities.69 Feeling restless.80 Not following through on instructions.63 Failing to finish work.74 Having difficulty engaging in leisure activities or doing fun things quietly a Having concentration problems.77 Having difficulty organizing tasks or activities.46 Avoiding, disliking, or being reluctant to engage in work that requires sustained mental effort a Being easily distracted Having difficulty waiting turns.65 Interrupting or intruding on others.71 Talking back to parents, teachers, or other adults.60 Completing sloppy work.58 Talking excessively.72 Losing things necessary for tasks or activities a Blurting out answers before questions have been completed.73 Being forgetful in daily activities.60 Engaging in reckless activities without considering the consequences Having poor peer relations.60 Not listening when spoken to directly.46 Having a comorbid diagnosis of depression.75 Acting without thinking Failing to give close attention to details or making careless mistakes in one s work.83 Being impulsive.62 Losing control of oneself Feeling on the go or driven by a motor.73 Performing poorly in school Leaving one s seat in situations in which seating is expected.65 Daydreaming.70 Note: Principal components factor analysis with varimax rotation was completed. In the interest of clarity, only factor loadings.40 or greater are listed. Var = variance accounted for. a. These items did not load on any factor. Perceptions of ADHD Following the procedure established in Study 1, the 21 items covering perceptions of ADHD were recoded into agree, neutral, and disagree. Chi-square analyses were completed for each item. There were significant differences between groups for 15 of the 21 items. See Table 7 for the results for all of the items. Discussion The present study sought to clarify the degree to which ADHD is viewed similarly in the United States and China. Both the symptoms critical to the diagnosis of ADHD and perceptions of the disorder were examined. Clearly, there are large differences in the ways that teach-

10 422 Journal of Attention Disorders / November 2005 Table 7 Perceptions of ADHD in the Two Samples of College Students American Chinese Agree Disagree Agree Disagree n (%) n (%) n (%) n (%) ADHD is overdiagnosed today. 68 (63) 25 (23) 5 (4) 81 (70)*** ADHD is underdiagnosed today. 15 (14) 71 (66) 81 (70) 5 (4)*** Medication for ADHD should be used only as a last resort. 64 (59) 28 (26) 11 (10) 92 (79)*** Most children with ADHD just need more discipline. 29 (27) 62 (57) 62 (53) 29 (25)*** Schools do not offer enough support services for children with ADHD. 72 (68) 14 (13) 99 (85) 11 (10)** Most children with ADHD don t try hard enough to help themselves. 19 (18) 61 (57) 44 (38) 35 (30)*** Teachers are supportive of children with ADHD. 36 (27) 30 (28) 98 (85) 9 (8)*** ADHD is often diagnosed by unqualified individuals. 34 (32) 36 (33) 57 (50) 22 (19)* ADHD is biologically based. 54 (50) 16 (15) 71 (61) 17 (15) Most children with ADHD are just as smart as other kids. 94 (87) 3 (3) 103 (89) 4 (3) ADHD children are more likely to be troublemakers than other children. 50 (46) 34 (32) 67 (58) 27 (23) You can often tell if a child has ADHD by looking at the way their parents act toward the child you don t always have to see the child to know. 5 (5) 85 (79) 24 (21) 45 (39)*** Medication should be used as a first line treatment for ADHD. 16 (15) 80 (74) 17 (15) 72 (62)* Parents of children with ADHD just don t know how to control their children. 18 (17) 77 (71) 41 (35) 48 (41)*** Almost all children with ADHD with outgrow it by their teens. 14 (13) 62 (57) 12 (10) 59 (51) Almost all children with ADHD will outgrow it by their early twenties. 22 (20) 46 (43) 14 (12) 45 (39) It is an embarrassment to the family to have a child with ADHD. 5 (5) 90 (83) 21 (18) 85 (73)** ADHD is a result of spoiling the child. 6 (6) 95 (88) 11 (10) 90 (78) It is the schools job to instill discipline for ADHD children when the parents have failed. 13 (12) 79 (73) 86 (74) 14 (12)*** Children with ADHD are just bored and need more to do. 13 (12) 81 (75) 87 (75) 11 (10)*** Children with ADHD are more creative than other children. 17 (16) 33 (31) 43 (37) 11 (10)*** Note: To enhance the clarity of the table, only agree and disagree responses are listed here. The remainder of the 226 participants were neutral. *p <.05. **p <.01. ***p <.001. ers and college students in China and the United States view ADHD. First, as hypothesized, it appears that the Chinese groups may be more attentive to the hyperactivity symptoms, whereas the Americans focus on both hyperactivity and inattentiveness. Although this difference is small and cannot be considered conclusive, it may account for some of the previously reported difficulties in using Western measures among Chinese samples. It is possible that the relative lack of importance of inattention in China might artificially lower scores on some scales, such as the Inattention scales of the CBCL and TRF, because raters might not fully attend to these symptoms. On the other hand, because hyperactivity appears to be somewhat more important in China, people might be overly aware of children s hyperactive behaviors and rate children in a more extreme manner on scales such as the Conners measures. Such a focus on hyperactive behavior would be consistent with cultural beliefs that discourage assertiveness to maintain social harmony (Alban-Metcalfe et al., 2002). However, it is critical to note that these results are very preliminary and the differences between the cultures were small. Future research is necessary before any conclusions may be drawn. Conversely, both the rankings of the importance of the symptoms and the factor analyses indicate that the disorder is viewed similarly, though not identically. Five symptoms were rated as being among the top 10 most critical features of ADHD by all four groups, and an additional two symptoms were agreed upon by three of the four groups. Furthermore, all four samples endorsed symptoms included in the DSM-IV-TR as being the most critical to diagnosis, suggesting that the DSM criteria reflect Chinese conceptions of ADHD as well as American conceptions. Thus, future research should clarify the degree to which the slight but apparent difference in the relative importance of inattention affects diagnosis in the two countries, given the high degree of similarity identified through factor analysis and rankings. For example, are American children with primarily inattentive symptoms more likely to receive the diagnosis than Chinese children with the same symptoms or, because both cultures weigh the symptoms similarly, would diagnosis be the same in both countries?

11 Norvilitis, Fang / Perceptions of ADHD 423 The second major result of the present study is that perceptions about the nature and treatment of ADHD are clearly disparate. Some of this is likely due to quantifiable differences between the cultures in terms of treatment. For example, it is common knowledge in the United States that psychostimulants are broadly prescribed. This is not the case in China. Participants ideas about overdiagnosis and use of medication are probably related to this knowledge. However, other items appear to reflect deeper cultural differences in attitudes. The two Chinese samples were more likely to endorse items indicating that ADHD reflects poorly on the families from which the children come and on the children s own effort level. The American samples, on the other hand, were less likely to view ADHD as a failure of discipline or parenting or the children s effort. Perhaps as a result of this difference, the Chinese samples were more likely to report that teachers are responsible to instill discipline in children with ADHD. It is also noteworthy that the Chinese samples report that teachers are supportive of children with ADHD more so than did the American samples, although all four samples were more likely to agree than disagree that schools do not offer enough support services for children with ADHD. The American teachers agree that children with ADHD are just as smart as other children and that they try hard to help themselves, but the fact that the teachers do not endorse medication, discipline, or more activities as ways to help these children may make them appear less supportive to others. An interesting paradox is that the Chinese teachers were more likely to report agreeing with the statement that ADHD is biologically based than were American teachers. However, the Chinese samples were also more likely to report that children with ADHD need to try harder, that parents of children with ADHD just don t know how to control their children, and children with ADHD are just bored and need more to do. The Chinese teachers also endorsed their own need to help children with ADHD, with 45% agreeing with the statement It is the schools job to instill discipline for ADHD children when the parents have failed. Thus, although endorsing biological causes as a root of the problem, the Chinese samples clearly believe in personal responsibility as a means of coping with ADHD, but they are also open to the use of medication. The American samples were much more reluctant to assign responsibility for the disorder and seemed much more skeptical about ADHD in general. More than 80% believe that the ADHD is overdiagnosed today, and more than 60% believe that medication should be used only as a last resort. At the same time, given the American samples disagreement with statements about children with ADHD needing to try harder and parents of ADHD children needing to control their children, it is not clear how the American samples think that ADHD is best treated or who is responsible for controlling the disorder. This ambivalence about medication and responsibility may pose a challenge for American therapists and psychiatrists. It should be noted that none of the items dealt with specific types of nonmedication therapies. Perhaps the American samples would have been more willing to endorse behavioral techniques or social skills training than the more general ideas of the items included in this study. Although the implications are significant, the present study does have limitations. Most notably, psychologists and psychiatrists, who are most responsible for diagnosis, were not included for logistical reasons. It is possible that their views of important symptoms may be somewhat different than teachers and students. Future research should replicate these findings in that population. Overall, it appears that the diagnosis of ADHD is similar but not identical in the two cultures. As a result, researchers should be wary of simply using Western norms and standards in assessing the presence of ADHD. However, the high degree of similarity between the two suggests, in agreement with Luk and Leung (1989), that the Western conception and, therefore, the Western scales may be appropriate for comparative, but not diagnostic, purposes. Of greater interest are the differences in perceptions about the disorder. The vastly disparate views of the disorder suggest that the diagnosis may lead to differences in treatment, expectations about prognosis, outcome, stigma attached by society, and support given to those with the disorder. Thus, the disorder may be roughly equivalent in China and the United States, but the meaning of the diagnosis appears to vary. Future research should explore this possibility, perhaps beginning with the acceptability of various treatments, including behavior therapy, for ADHD in the two countries and whether treatments are differentially effective across cultures. References Alban-Metcalfe, J., Cheng-Lai, A., & Ma, T. (2002). Teacher and student ratings of attention-deficit/hyperactivity disorder in three cultural settings. International Journal of Disability, Development, and Education, 49,

12 424 Journal of Attention Disorders / November 2005 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Goldstein, S. (1996, November). Attention deficit hyperactivity disorder in adults: What we know, think we know, and need to know. Paper presented at the 16th Annual National Academy of Neuropsychology Conference, New Orleans, LA. Ho, T. P., Leung, P. W. L., Luk, E. S. L., Taylor, E., Bacon-Shone, J., & Mak, F. L. (1996). Establishing the constructs of childhood behavioral disturbance in a Chinese population: A questionnaire study. Journal of Abnormal Child Psychology, 24, Leung, P. W. L., & Connelly, K. J. (1996). Distractibility in hyperactive and conduct-disordered children. Journal of Child Psychology and Psychiatry and Allied Disciplines, 37, Leung, P. W. L., Ho, T. P., Luk, S. L., Taylor, E., Bacon-Shone, J., & Mak, F. L. (1996). Separation and comorbidity of hyperactivity and conduct disturbance in Chinese schoolboys. Journal of Child Psychology and Psychiatry and Allied Disciplines, 37, Leung, P. W. L., Luk, S. L., Ho, T. P., Taylor, E., Mak, F. L., & Bacon- Shone, J. (1996). The diagnosis and prevalence of hyperactivity in Chinese schoolboys. British Journal of Psychiatry, 168, Li, X. R., Su, L. Y., Townes, B. D., & Varley, C. K. (1989). Diagnosis of attention deficit disorder with hyperactivity in Chinese boys. Journal of the American Academy of Child and Adolescent Psychiatry, 28, Liu, X., Kurita, H., Guo, C., Tachimori, H., Ze, J., & Okawa, M. (2000). Behavioral and emotional problems in Chinese children: Teacher reports for ages 6 to 11. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41, Luk, S. L., & Leung, P. W. L. (1989). Conners Teacher s Rating Scale A validity study in Hong Kong. Journal of Child Psychology and Psychiatry and Allied Disciplines, 30, Luk, S. L., Leung, P. W. L., & Lee, P. L. M. (1988). Conners Teacher Rating Scale in Chinese children in Hong Kong. Journal of Child Psychology and Psychiatry and Allied Disciplines, 29, Mann, E. M., Ikeda, Y., Mueller, C. W., Takahashi, A., Tao, K. T., Humris, E., et al. (1992). Cross-cultural differences in rating hyperactive-disruptive behaviors in children. American Journal of Psychiatry, 149, Matsuura, M., Okubo, Y., Toru, M., Kojima, T., He, Y., Hou, W., et al. (1993). A cross-national EEG study of children with emotional and behavioral problems: A WHO collaborative study in the Western Pacific region. Biological Psychiatry, 34, Norvilitis, J. M., Scime, M., & Lee, J. S. (2002). Courtesy stigma in mothers of children with attention-deficit/hyperactivity disorder: A preliminary investigation. Journal of Attention Disorders, 6, Salili, F., & Hoosain, R. (1985). Hyperactivity among Hong Kong Chinese children. International Journal of Intercultural Relations, 9, Tao, K. T. (1992). Hyperactivity and attention deficit disorder syndromes in China. Journal of the American Academy of Child and Adolescent Psychiatry, 31, Yang, K. N., & Schaller, J. (1997). Teachers ratings of attentiondeficit hyperactivity disorder and decisions for referral for services in Taiwan. Journal of Child and Family Studies, 6, Yang, K. N., Schaller, J. L., & Parker, R. (2000). Factor structures of Taiwanese teachers ratings of ADHD: A comparison with U.S. studies. Journal of Learning Disabilities, 33(1), Yu-cun, S., Yu-feng, W., & Xiao-Ling, Y. (1985). An epidemiological investigation of minimal brain dysfunction in six elementary schools in Beijing. Journal of Child Psychology and Psychiatry and Allied Disciplines, 26, Jill M. Norvilitis is an associate professor of psychology at State University of New York College at Buffalo. Ping Fang is the vice president of the Education Science College and dean of the Department of Psychology at Capital Normal University in Beijing, China.

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