Critical Appraisal of ADHD Prevalence in Children and Adolescents

This essay critically appraises the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents, focusing on the UK context. It explores the disorder's characteristics, including inattention, hyperactivity, and impulsivity, and highlights the increasing rates of diagnosis, particularly within specific ethnic groups. The essay delves into developmental theories, such as Piaget's cognitive development and Vygotsky's socio-cultural theories, to explain the cognitive and social challenges faced by children with ADHD. It examines sociological and psychological factors, including cultural values, gender roles, and parental beliefs, that contribute to the disorder's etiology and influence help-seeking behaviors. The essay also critiques existing initiatives for supporting children with ADHD and discusses policy and ethical implications for improving child mental health services, emphasizing the need for increased awareness, culturally competent care, and family engagement to address disparities and enhance the quality of life for those affected by ADHD.

Running head: CHILD AND ADOLESCENT MENTAL HEALTH
Child and adolescent mental health
Name of the student:
Name of the University:
Author’s note

1CHILD AND ADOLESCENT MENTAL HEALTH
Attention deficit hyperactivity disorder (ADHD) is the most misunderstood and neglected
mental health condition that mostly affects school-age children and young people in UK. Very
few people receive appropriate diagnosis or treatment leading to increase in prevalence of the
condition (rota.org.uk 2013). ADHD is a type of mental disorder associated with symptoms of
inattention, hyperactivity and impulsivity that persists for a long time and interferes with the
development of children. (Tresco, Kessler and Mautone 2017). ADHD is a highly heritable
disorder as children have a higher chance of developing the condition if their parents are
diagnosed with ADHD. Globally, the prevalence rate of ADHD is 5.29% (Smith 2017).
Although genetic factors have been found to cause of ADHD, however, there are many
arguments regarding the factors contributing to ADHD and impact of the condition on child
development. The disease is also regarded as a socially or culturally constructed condition
because of links between social factors and increase in risk of ADHD. Such kind of
interpretation influences the process of managing the disorder and seeking services to treat the
mental health condition. To gain better idea about the way to manage the condition, the primary
purpose of this essay is to critically appraise ADHD prevalence in children and adolescents by
discussion on theories of child development and identifying sociological and psychological
factors that contribute to the disorder in children. The essay also critiques existing initiatives that
have been implemented for supporting children with ADHD and discuss policy or ethical
implications to improve child and mental services.
The mental health issues of ADHD prevalence has been specifically chosen as a topic for
the essay due to the increase in rate of ADHD diagnosis in children, unequal representation in
ethnic group and increase in risk of behavioral issues in later life of children and adolescent. The
number of children diagnosed with the condition has increased by 5% per year from 2003 to

2CHILD AND ADOLESCENT MENTAL HEALTH
2011 (Smith 2017). According to a recent survey done in the US in 2016, the number of children
diagnosed with ADHD was 9.4%, and these children also suffered from other issues like
behavioural problem, anxiety and autism (cdc.gov 2016). The estimated prevalence rate of the
condition in the UK is 3.6% in children between 5-15 years because of DSM-IV criteria. The
prevalence of ADHD London’s Black and Minority Ethnic (BAME) community is also
increasing because of the prevalence of unfair and prejudicial experience in children (rota.org.uk
2013). They are over-represented among diagnosed or mis-diagnosed cases of ADHD because
of stigma around the condition and lack of public knowledge regarding the mental health issue
(Rees 2016). Hence, critical understanding links about social and psychological factors that
contribute to ADHD is necessary to change perception of people and improve mental health
services for recovery of children and adolescent diagnosed with ADHD.
As the main aim of the essay is to critical discuss the prevalence of ADHD in children,
finding links between development theory and ADHD may help to identify individual at high
risk of developing the mental disorder. Mental health is defined as a state of emotional,
psychological and social well-being. In contrast, mental illness is a condition that results in
negative changes in thinking, emotion and behavior of an individual (Rogers and Pilgrim 2014).
The transition from mental health to mental illness is understood from different developmental
theories such as social learning theory, humanistic theory, psychoanalytical theory and
attachment theory. The nature versus nurture theory is a debate on the role of nature or nurture
on mental illness. Nature refers to the role of hereditary factors and genetic factors on one’s
personality, whereas nurture is related to all environmental variables that has an impact on
development of an individual (Coll, Bearer and Lerner 2014). Hence nature and nurture is linked
to explain the cause of mental illness. For example, a pregnant woman with major emotional loss

3CHILD AND ADOLESCENT MENTAL HEALTH
in the early stage of pregnancy is at high risk of schizophrenia. Large genetic influence on the
developmental course of ADHD symptom was proved by Pingault et al. (2015) and the
developmental interface between nature and nurture was explored by Harold et al. (2013) by
investigating about biological and rearing mother influences on child ADHD symptoms. The
study proved the role of maternal parenting behavior on course of children’s ADHD symptoms
and the role of early disrupted child behavior on children’s later ADHD symptoms. Hence,
addressing parenting practices may be crucial to reduce development of ADHD symptom in
children with time.
Jean Piaget's cognitive development theory and Vygotsky’s socio-cultural theories can
explain the reasons for negative symptoms like poor concentration and poor focus in n children
with ADHD. For example, according to Piaget's cognitive development theory, children start
developing formal and organized thought during the concrete operational stage (7-11 years of
age). However, children are diagnosed with ADHD at this stage. Children and youths can use
abstract thought and observational skills to understand people’s need. However, it can also lead
to social and emotional challenges for youths if they use their cognitive abilities to compare
themselves with others. Such thought pattern leads to negative consequences for children. This is
the reason for poor learning ability and poor focus in children with ADHD (Yanagisawa 2016).
Shoham et al. (2016) argues that children with ADHD may engage in risk taking behavior in the
future because of their subjective experience. They find risk taking to be appealing for them. The
psychoanalytic theory explains regarding the dynamics of personality development by explaining
human behavior in terms of interaction with various components of personality. This theory finds
application in the interpretation of inner world of ADHD children. It can shed light about the
child’s experiential world and the factors contributing to negative behavioral outcome in them

4CHILD AND ADOLESCENT MENTAL HEALTH
(Salomonsson 2017). Vygotsky’s theory concentrates on the impact of the social system on child
development and this theory may be utilized to explain how social factors influence the severity
of ADHD (Sawyer 2017).
Diagnosis of ADHD in children and adolescent results in many challenges both the child
and their parents. For instance, social functioning and academic performance of children is
significantly impaired and the stress level of parents increases. Another negative impact of the
condition is that ADHD significantly contributes to social challenges for children as the
condition worsens social skills and results in inattention from peers and poor parent-child
relationship (Keen and Hadjikoumi 2011). Identifying and looking for sociological or
psychological links contributing the disorder may help to better manage the condition and
reduce risk of diagnosis in children and adults in UK. The etiology of ADHD is understood
differently by different people. Some link it to clinical factors whereas others link the
development of ADHD with cultural, social and psychological factors of an individual.
As parental beliefs about the etiology of ADHD influence the help-seeking behaviour and
service uptake rate, Lawton et al. (2014) focused on evaluating the role of cultural values,
traditional gender roles and spirituality to explain parental beliefs about etiology. The research
was done with Latino parents and Latino children with ADHD were found to have a higher
unmet need (Zimmerman 2005). Research in this area was necessary because their perception
influences the response they take and the type of service they visit for the care of their child
(Ahmed et al. 2017). From the statistical review of parent’s response, it was found that 69.08%
of parents endorsed bio-psychosocial etiological beliefs whereas 32.5% supported spiritual
beliefs. Traditional gender role and Anglo orientation was the main reason for parents to
consider a child's friend to be contributing to ADHD (Lawton et al. 2014). These factors were

5CHILD AND ADOLESCENT MENTAL HEALTH
also the reason for parents to report about spiritual factor and nature disharmony as the cause of
ADHD. The factors that influenced adherence to ADHD medication in adolescents included
negative attitude towards medications, stigma, experience of social withdrawal and issues related
to treatment independence (Bhang et al. 2017).
Gender wise differences in self-perception of ADHD have been found among children
and adolescents too. Children and adolescent with ADHD are at high risk of emotional and social
problems like risk taking behavior, suicide, depression and addiction due to pervasive nature of
symptoms. Adolescent girls have lower self-efficacy and poor coping strategies than adolescent
boys with ADHD due to more internalizing problems and diminished self-efficacy. Hence,
school performance, peer relationship and acceptance to the condition influence self-esteem and
self-concept in adolescent. Early intervention is needed to prevent such emotional injuries in
adolescents with ADHD (Houck et al., 2011).
The explanation by Lawton et al. (2014) shows that cultural values and traditional gender
role are strongly associated with parent's tendency to favor sociological factor as the cause of
ADHD. Bussing et al. (2015) argued that racial and social demographic disparities in care exist
due to parental social networks, which influence the help-seeking process. Hence reasons for
differential help-seeking behaviour in parents to treat ADHD is understood and this provides the
clinical implication to target parents to make them aware about etiology of ADHD and suggest
mental health services for the child. Engaging parents in care process may also help to provide
culturally competent care and improve parent’s satisfaction with mental health care service. In
future, health care workers and staffs must focus on increasing knowledge about idea about
ethnic group differences in relation to the understanding of the cause of ADHD.

6CHILD AND ADOLESCENT MENTAL HEALTH
Exploring the knowledge, perception and information sources of parent, adolescent
children may also help to establish sociological or psychological risk concerning the disorder.
Bussing et al. (2012) used the health belief model to predict health-related behaviour of
individuals, and in the study, the participant's awareness of the health condition was judged to
understand the need for psycho-educational intervention for prevention of ADHD. The survey-
based research tested predictor variable of ADHD knowledge, level of mental health service use
and ADHD knowledge and cues to action. The review of survey result indicates that parents and
adolescents had many misconceptions related to the cause of ADHD. For example, there were
some groups who regarded sugar as the cause of ADHD and some linked ADHD to medication
overuse. Regarding predictors of ADHD knowledge, the racial background was found to be the
most common predictor of knowledge for adolescents as Caucasians were found to have higher
knowledge related to ADHD compared to African American. However, for parents, their child's
past mental health service used was the standard predictor of knowledge (Bussing et al. 2012).
It is evident that ADHD knowledge of people is influenced by their racial background. In
contrast to the research by Lawton et al. (2014), Bussing et al. (2012) emphasized more on
predictors of knowledge instead of evaluating the cultural values related to ADHD knowledge.
The belief regarding sugar etiology of ADHD also reflects old popular opinion is still high
among racial group instead of believing scientific facts about ADHD. The evidence proves that
knowledge about ADHD is low among ethnic group and poor pervasive belief is the reason for
disparities in ADHD care which is consistent with other research (Siegel et al. 2015). Hence, the
discussion give implications for improving health information exchange between care providers
and racial group to address disparities in care and improve quality of life of people affected by
ADHD. The discussion provides an insight that by evaluating participant's preference for ADHD

7CHILD AND ADOLESCENT MENTAL HEALTH
information source, the credibility of ADHD information available on the internet can be
improved so that misconception of people can be addressed (Rosenblum and Yom-Tov 2017).
The most important implication is that low awareness of ADHD points to the need to increase
communication between patient and care provider to increase uptake of services in the ethnic
group.
Racial and cultural factors also influence awareness of about ADHD among adolescent
and parent suggest that family engagement is necessary for treatment of children with ADHD. It
implies that family-centred care is needed for treatment of sensitive disorders like ADHD and the
advantage of such type of care is that it increases adherence to treatment and patient satisfaction
with care. Davis et al. (2012) focused on investigating about the perspective of parent's
perception about family-centred care for ADHD. The review of interview transcript revealed that
majority of participants did not prefer shared decision making process and they mainly had the
perception that parents are responsible for deciding on ADHD treatment. Also, the family
perspective regarding the causes of ADHD was evaluated by taking four domain of internal
factors and external factors to the child, mix of both and developmental perspective. Internal
factors were related to genetic factors and personality of children, and the external factor was
related to environmental stressors and family separation factor. In this area, families were found
to be confused about the cause of ADHD, and their perspective also changes with time after
complex interaction with healthcare providers. Stress level is also a factor that influences
treatment choices of parents, and in this area, the majority of people reported experiencing
emotion stress (Davis et al. 2012). The evidence highlights the critical components of family-
centred care for ADHD and the need to address non-medical needs of patients and families. The

8CHILD AND ADOLESCENT MENTAL HEALTH
research outcome can be utilised by family-centered medical home to identify needs of children
and parents while development treatment programs for ADHD (Kuo et al. 2011).
The impact of culture and social factors on parent’s ADHD knowledge and help-seeking
behaviour and preferences for mental health services is understood from the discussion so far.
However, the uniqueness of the population-based longitudinal study by Galéra et al. (2014) is
that it focused on investigating the impact of behavioural and environmental factors on ADHD
medication use. Taylor (2014) argued that the effectiveness of ADHD treatment is hampered due
to the use and misuse of ADHD treatment. This research was significant to understand the reason
behind overuse and underuse of medication. Using longitudinal study design, data were
collected by interview with participating families, and the primary outcome measured included
ADHD medication use. The review of the statistical analysis of research data revealed that the
level of ADHD medication use dependent on core symptoms of ADHD and also using low
maternal education, gender and immigrant status. The most robust clinical predictor for ADHD
as medication use was hyperactivity-inattention thus indicating that no medication was
prescribed for the patient having an anxiety problem. By the analysis of cultural trends in
medication use, it was also found that mothering ideology and masculinity stereotypes affected
medication use pattern. For example, adolescent boys were more likely to use medication for
ADHD compared to girls (Galéra et al. 2014). This study outcome proved the fact that social
variables influenced the rate of ADHD medication use instead of psychiatric comorbidity or
parenting style. This evidence points out to the factors contributing to disparities in treatment and
develop ways to offer same intervention to all groups irrespective of cultural differences.
Galéra et al. (2014) explained the role of genetic and environmental factors contributing
to ADHD, social and cultural characteristics influence the diagnostic process and prescription of

9CHILD AND ADOLESCENT MENTAL HEALTH
ADHD medication too. The findings presented by Galéra et al. (2014) exemplify that factors that
contribute to biases in medication use. The credibility and validity of the research finding have
also been enhanced by taking a large sample group and consideration of other behavioural
symptoms of ADHD. However, the limitation found in current research is that the severity of
symptoms was not considered which leaves a significant gap in research. It was necessary to
review the severity of symptoms as this factor greatly determines the rate of medication use.
Secondly, the cultural and environmental factors of the different country may be various. Hence
it cannot be generalized to all setting. However, it provided practical implications for clinicians
to consider the social context of children with ADHD to improve adherence to therapeutic
intervention (Bhang et al. 2017).
The perception related to quality of life is an important parameter that determines a
patient's ability to cope with the disease in life. Sciberras, Efron and Iser (2011) used cross-
sectional survey method to compare the self-perception of parent and children with ADHD
related to the quality of life (QoL). The strength of the study is that it focused on analyzing the
perception of both parents and children and this would help to understand the strength of families
in coping with ADHD. Children with ADHD were recruited from an outpatient clinic, and the
other necessary variables like family history, education of parents and gender were considered.
Validated tools were also used for collecting data on quality of life in subjects. The statistical
analysis of differences between self and parent-reported child QoL revealed that differences in
perception as parents reported their child’s QoL as lower compared to their child. The evidence
depicted discrepancy between parents and child reported QoL. This research evidence indicates
that children were more optimistic regarding their future and QoL compared to parents. The
research is consistent with previous work discordance between parents and child’s view on

10CHILD AND ADOLESCENT MENTAL HEALTH
symptoms always occurs (Coker et al. 2016). However, the limitation of the work is that the
study failed to uncover the factors that lead to such perception in parents. Harpin et al. (2016)
argued that self-esteem attributes and community attitudes also influence adolescents and their
parent's ability to cope with ADHD. Hence, to promote efficiency in treatment, it is necessary
that clinicians communicate effectively to know about the experience of ADHD from families. It
would help to understand coping abilities and stress level of parents, and it would support
clinicians to deliver effective therapy both for the child and the family.
By the review of the research work by Sciberras, Efron and Iser (2011), it was found that
parents, children and adolescent coping behavior and perception related to QoL was influenced
by their experiences in the community after the diagnosis of ADHD. In this context, getting an
idea about the role of stigma on ADHD perception and challenges for children is also essential.
dos Reis et al. (2010) examined the experience of parents whose child received an initial
diagnosis of ADHD. By interviewing parents about their experiences leading ADHD diagnosis
and treatment, it was found that about 77% of participants reported about the experience of
stigmatization due to ADHD. Due to experience of stigma, parents were concerned about their
children and experienced self-isolation and rejection in society. The research study is critical to
understand and address stigma as research has shown that stigmatization also affects parent's
decision to seek treatment (Mikami et al. 2014). Mueller et al. (2012) also showed that stigma
results in maladaptive cognitive behavior in adolescents and influences emotional well-being of
adolescents who are at high risk for ADHD. Hence, one important implication of this evidence
is that it highlights the need for improved community outreach programs too so that parents and
children with ADHD do not suffer additional burden and do not associate ADHD with shame
and guilt.

11CHILD AND ADOLESCENT MENTAL HEALTH
The role of social divisions on ADHD knowledge and uptake of mental health service is
understood from above critical review of research literature. Social division in society implies
the difference in treatment of an individual’s by race, class and ethnicity. As the cultural values
and social beliefs of families from different racial background or ethnicity are different, this
factor has an impact on decision making and care for children with ADHD. A study done in two
racial group explained that racial background resulted in differences in belief about ADHD. For
instance, African subjects have been found to have a lower level of ADHD knowledge compared
to Caucasian thus indicating racial/ethnic variations in ADHD knowledge Bussing et al. (2012).
From this explanation, it is understood that misconception and lack of awareness about causes of
ADHD are highly prevalent due to social divisions of society. Hence, there is a need to provide
culturally competent care along with the integration of appropriate health care model so that all
population group irrespective of racial or class difference received the same treatment and
attention from mental health services. The family-centered approach is also a necessity to
address the deficit of knowledge and poor attitude towards seeking help in the parent (Davis et
al. 2012). Such steps can contribute to strengthening parenting skills and improving health
outcome of children with ADHD (Zajicek-Farber et al. 2015).
Many psychosocial factors increase the risk of severity and psychiatric comorbidity in
children with ADHD. For example, experiences of stigma and exclusion increase the
psychological risk for ADHD children. Stigma perception or experience of stigma results in
adverse mental outcome such as poor self-esteem, social stigma. Such individual is at risk of
psychiatric disorders along with ADHD (Mueller et al. 2012). For instance, depression and low-
esteem are common in children with ADHD. It implies that changing the attitude of parents is
not enough; there is a need to address adverse psychological risk factors for ADHD.