Underdiagnosis and Undertreatment of ADHD in the South Asian Demographic
Attention-deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children and adolescents. ADHD is characterized by two main symptom groups – inattention and hyperactivity. Symptoms must be present in two or more settings before the age of twelve, and must significantly impact social or academic functioning. The dual pathway model explains the heterogeneity of ADHD symptoms; one affected neurological pathway is responsible for cognitive control and self-regulation, while the other is linked to reward processing and emotional regulation (Drechsler et. al, 2020). Cultural and social context can greatly impact the symptoms, presentation, and experience of individuals with ADHD, as no mental health condition is purely biological. In South Asian children and adolescents, ADHD is underdiagnosed and undertreated because of social and cultural factors, such as parenting styles and the emphasis on alternative medicine, that contribute to a stigma surrounding mental health, differing diagnostic criteria, and lack of access to mental health services.
The authoritative parenting style commonly seen in South Asian cultures is both a product of and contributing factor to the stigma surrounding mental health, making affected individuals less likely to report symptoms and seek treatment, while simultaneously exacerbating symptoms. In South Asian families, key cultural values, such as respect for authority and an emphasis on academic excellence, strongly influence parenting practices. In order to encourage academic and professional success, South Asian parents generally lie on the more authoritarian end of parenting styles (Patel et. al, 2024). One hypothesis for the effect of parental influence is that authoritarian parents regulate and monitor their children’s behavior more, so they would be more likely to recognize symptoms and seek treatment for their child. However, the authoritarian approach to parenting coupled with the deep-rooted mental health stigma in South Asia leads to children associating their ADHD with shame and guilt rather than feeling comfortable practicing self-advocacy. A case-control study that examines parenting styles in parents of children with ADHD compared to parents of those without ADHD found that “parents of children with ADHD had significantly lower permissive parenting scores (M = 27.4, SD = 4.4)” and “the authoritarian parenting score was significantly higher among parents of children with ADHD (M = 23.5, SD = 6.1)” (Patel et. al, 2024). This greater control and stricter imposition of rules could be a response to the child’s ADHD symptoms, but this approach to parenting may only exacerbate symptoms by “failing to provide the emotional support and flexibility needed by children with ADHD” (Patel et. al, 2024). While this study demonstrates a positive correlation between level of authoritative parenting and ADHD prevalence, it does possess limitations. Due to its reliance on parental self-report, social desirability bias may cause parents to understate punitive measures they take with their children. Additionally, this study looks at a culturally homogeneous sample in Iran, which does not match the South Asian demographic and inhibits generalizability. However, currently there is limited research available on ADHD in South Asians, so the lack of evidence is evidence in itself to emphasize the need for greater attention on this demographic.
The correlation between authoritative parenting and ADHD diagnosis could indicate that strict parenting worsens ADHD symptoms, and more prominent symptoms can facilitate diagnosis. However, there is actually a lower prevalence rate of ADHD, with South Asians being “71% less likely to be diagnosed with ADHD” and have “88% lower odds of self-reporting their ADHD diagnosis when compared to Caucasian youth” (Patel et. al, 2024). This lower prevalence rate seems to refute the idea that stricter parenting exacerbates ADHD symptoms, which posits the question of why these amplified symptoms are not leading to greater ADHD diagnosis and prevalence in South Asians. ADHD remains underdiagnosed in South Asians because of the stigma surrounding mental health culturally. The same core value of academic excellence that contributes to strict parenting also creates a stigma surrounding mental health, as South Asian culture views ADHD as a weakness that prevents people from attaining academic success and renders them inferior. Emphasis on collectivism in South Asian culture also leads family members to see one relative’s failure as being reflective of the entire family’s status. Therefore, the authoritarian parenting style that is characteristic of South Asian parents invalidates the experience of ADHD children, making them feel lesser and pressuring them to conceal symptoms to preserve the family image. This phenomenon contributes to underdiagnosis and undertreatment of ADHD in South Asian adolescents as parents dissuade or even prevent their children from seeking medical care, since a label such as ADHD coincides with a negative connotation and powerful stigma in their culture.
The mental health stigma in South Asian countries leads to the under-prioritization of mental health infrastructure, as well as lack of access to mental health services and resources. One study examines Faridabad, the largest district in the state of Haryana in Northern India; mental healthcare professionals are only available at the secondary care setting, and there are only two secondary care hospitals in the entire district (Kaur et. al, 2023). The lack of healthcare infrastructure leads to under-resourced, overcrowded hospitals where people cannot receive the care that they deserve, as well as a more difficult commute if the nearest hospital is far away. Due to lack of resources and overcrowding, doctors have little time to actually meet with their patients and discuss concerns. During their field visits, the researchers in Faridabad “observed many patients satisfied with getting five minutes of [the] psychiatrist’s attention after waiting for a long time and did not bother to ask questions about their treatment or diagnosis… More focus was seen on prescribing psychotropic medications, out of which many were not available even at the district level pharmacy” (Kaur et. al, 2023). As Thomas Insel states, the overmedicalization of mental illness and reliance on pharmaceutical drugs is not an adequate solution, and community-based therapeutic strategies are important in treatment or recovery (S. Gibbons, personal communication, January 23, 2025). The lack of trained mental healthcare professionals is a glaring issue in developing countries such as India, as it contributes to underdiagnosis and undertreatment of over-stigmatized and misunderstood conditions such as ADHD.
Building on the lack of healthcare providers, the existing ones further reinforce the stigma by using derogatory language to describe mental illness. In interview transcripts from Faridabad, healthcare users and providers alike described stigmatizing Hindi phrases used for people with mental health conditions: “paagal (mad), aalsi (lazy), moti-buddhi (fat-head), bewakoof (idiot), dimag khisak gaya (lost mind)” (Kaur et. al, 2023). Replacing neutral, unbiased medical terms with these disparaging expressions only bolsters the stigma surrounding mental health, fortifying the notion that mental illness is a manifestation of incompetence and inferiority. In addition to these belittling phrases, healthcare providers in Faridabad also invalidated the experience of patients with ADHD in the recorded transcript of their conversation: “What can be the problem with her mind, she is getting everything, we are fulfilling her basic needs, she is doing this intentionally because she is lazy” (Kaur et. al, 2023). The invalidation of ADHD symptoms prevents those affected from receiving treatment that they need, as South Asian healthcare providers dismiss concerns of an inability to focus or perform well academically as mere laziness. This response from healthcare professionals not only impedes diagnosis and treatment of ADHD, but it also dissuades people with such stigmatized conditions from seeking medical attention in the first place in fear of being judged or disregarded.
Another display of insufficient treatment methods in South Asia is the cultural bias toward alternative medicine, which is problematic as homeopathic and ayurvedic treatments possess lower efficacy in treating ADHD. In the Faridabad study, “all participants indicated that the first point of contact for them for seeking treatment for mental illnesses were religious and traditional healers… who use hot tongs to brand and shock the individuals, or hang some individuals upside down” (Kaur et. al, 2023). Again due to the stigmatization of mental health, South Asian cultures consider mental illnesses to be the direct result of sinning, so they believe that prayer, worship, and atonement are enough to cure them. Spiritualists and traditional healers provide solutions that only worsen an individual’s health and make no effort to target the actual symptoms, but many South Asians believe in this alternative medicine, which is not a satisfactory substitute; this cultural preference magnifies the phenomenon of undertreatment. Homeopathy is a branch of alternative medicine that uses small doses of natural substances, which would produce disease in a healthy person. The results of a pilot randomized-controlled trial to evaluate the effectiveness of homeopathic treatments on ADHD found that “there were no statistically significant differences between homeopathic remedy and placebo groups on the primary or secondary outcome variables” (Jacobs et. al, 2005). The two variables in the experiment are inattention and hyperactivity, the two core dimensions of ADHD; just like a placebo, homeopathic treatment had no effect on either. Homeopathy neither lengthened attention span nor diminished hyperactivity in the trial, so it does not appear to be an effective treatment for ADHD. However, more studies must be conducted before researchers can confidently accept the null hypothesis. Effective treatments include both a pharmacological component – medication such as methylphenidate and lisdexamfetamine – and a nonpharmacological component – cognitive behavioral therapy. In combination, these can significantly reduce ADHD symptoms (Drechsler et. al, 2020). The preference for alternative remedies in South Asian countries such as India is harmful as it neglects extensively researched, effective treatments in favor of pseudoscience.
In South Asia, neurodevelopmental disorders such as ADHD are wrongfully stigmatized – far more than in other cultures – due to the burden of cultural expectations that parents place on their children and lack of information about mental health. It is important to destigmatize mental illness as going undiagnosed or untreated can lead to problems managing symptoms and understanding one’s self-identity. If more attention is brought to the phenomenon of underdiagnosis, developing countries such as India can allocate more resources to bolstering mental healthcare infrastructure. Currently, the bias toward homeopathic and ayurvedic medicine in South Asian culture prevents individuals from receiving treatment that they need, which could be harmful as such alternative remedies have demonstrated inefficacy in clinical trials. Additionally, South Asian parenting styles can invalidate the experience of a child with ADHD, so with greater awareness the parenting norm can evolve to be more accommodating to the diverse needs of their children. As the South Asian population is heavily understudied, researchers must prioritize this demographic to foster awareness and facilitate both diagnosis and treatment.
References
Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current Concepts and Treatments in Children and Adolescents. Neuropediatrics, 51(5), 315–335. https://doi.org/10.1055/s-0040-1701658
Jacobs, J., Williams, A.-L., Girard, C., Njike, V., & Katz, D. (2005). Homeopathy for attention-deficit/hyperactivity disorder: A pilot randomized-controlled trial. The Journal of Alternative and Complementary Medicine, 11(5), 799–806. https://doi.org/10.1089/acm.2005.11.799
Kaur, A., Kallakuri, S., Mukherjee, A. et al. Mental health related stigma, service provision and utilization in Northern India: situational analysis. Int J Ment Health Syst 17, 10 (2023). https://doi.org/10.1186/s13033-023-00577-8
Patel, P., Behl, J., Karim, T., Palnati, S. R., & Bhakta, S. (2024). Parenting Styles and Attention Deficit Hyperactivity Disorder in the South Asian Population: A Narrative Review. Cureus, 16(12), e74967. https://doi.org/10.7759/cureus.74967
