The social and developmental context in which behavior occurs is what distinguishes normal from disordered behavior; deciding what is inappropriate development or harmful dysfunction is ultimately a social judgment (Munir & Beardslee, 2001
; Kirmayer & Young, 1999
; Lilienfeld & Marino, 1995
; Pine et al., 2002
; Wakefield, 1999
) that may differ across cultures. Cultural and ethnic groups differ with regard to practices and activities relevant for ecocultural adaptation and survival (Weisner, 2002
). Given these cultural differences, some investigators adhere to a relativistic view (Lewis-Fernandez & Kleinman, 1995
; Rogler, 1996
; Wakefield, Pottick, & Kirk, 2002
; Weisz, Weiss, Suwanlert, & Chaiyasit, 2006
), others to a universalistic view (Roberts & Roberts, 2007
; Bird, 2002
), while still others to a combined universalistic/relativistic view (Rutter & Nikapota, 2002
A great number of investigators, particularly in the area of psychiatric epidemiology, adhere solely to a universalistic view of psychopathology. The basic premise of the universalist view is that psychiatric disorders and syndromes are universal and have core symptoms that cluster into universal syndromal patterns. According to this view, what could vary across cultures or sub-groups within a culture is the symptomatic manifestation of the disorder or the threshold of what is considered pathological versus normal behavior (Canino, Lewis-Fernandez, & Bravo, 1997
). Thus, the same internal disorder can be manifested differently in different cultures but the underlying psychopathology is the same across cultures. This concept has been coined by Weisz, McCarty, Eastman, Suwanlert, and Chaiyasit (1997)
as ethnotypic consistency
, related to the notion of heterotypic continuity
or the idea that a trait or disorder may manifest itself differently at different developmental stages. An example of ethnotypic consistency (Weisz et al., 1997
) is the way disobedience is manifested in Anglo cultures versus the Thai culture. In the Anglo culture, the child exhibits disobedience with external and direct behavior and by overtly refusing to comply with the adult’s request. In the Thai society, disobedience is manifested by the child looking uninterested, or hesitating, signaling his unwillingness to obey. However, in both societies disobedience, when it is accompanied by a cluster of other defiant behaviors, is recognized as a symptom of oppositional defiant disorder. The assumption of the universalist is that the same set of criteria and symptom clusters is observed across cultures, or the same set of syndromal clusters, even if the manifestation of the symptom varies cross-culturally.
The universalist position exemplified by DSM-IV states that although disorders are caused by internal dysfunction, this dysfunction may originate from exposure to negative environments. Thus, contrary to what is commonly believed, the universalist position does not negate that risk and/or protective factors related to the pathogenesis of the disorder may affect the various manifestations of the disorder. In fact, for each disorder DSM-IV has a section on Specific Culture, Age and Gender Features that is intended to guide the clinician on variations of the disorder that may be attributable to the individual’s culture, sex or developmental stage. Nevertheless, DSM-IV has not formally incorporated social or cultural factors as exclusionary criteria of disorders. The difficulty lies in distinguishing between behaviors caused by negative environments that do not involve internal dysfunction and those that originate from negative environments but involve internal dysfunction (Wakefield, Pottick, & Kirk, 2002
). For example, as stated by Rutter and Nikapota (2002)
, deprived environments may cause enduring biological dysfunctions in empathy and impulse control characteristic of conduct disorders, but the same environment may also cause non-disordered youth to react in socially undesirable ways out of motives of self-protection or social conformity.
has been critical of this position, stating that DSM-IV is supposed to be a descriptive nosology system, free of etiological inferences and causality. He states that although clinicians, through painstaking and time-consuming work, can make the inference of causality, there is no way in which the distinction between conduct behaviors that are symptoms of an internal dysfunction from those that are reflections of a negative environmental context can be made in epidemiologic surveys. In fact, Bird (1996)
, contrary to other investigators (Wakefield et al., 2002
), concurs with the direction of the DSM-IV that has not formally incorporated social or cultural factors as exclusionary criteria for disorders.
The relativistic point of view claims that culture shapes the individual’s development and his/her biological and psychological unfolding to a substantial degree, with the need to integrate culture within the diagnostic classificatory system (Lewis-Fernandez & Kleinman, 1995
). According to the relativists DSM excludes important cultural symptoms and syndromes unique to particular cultural settings that results in a category fallacy or apparent homogeneity of disorders across cultures (Kleinman & Kleinman, 1991
). The main premise of this point of view is that cultural settings shape definitions of normality and pathology, the number and duration of symptoms required for defining impairment, and the phenomenology of the disorder as well as the course and response to treatment of the syndromes (Lewis-Fernandez & Kleinman, 1995
). Relativists question the internal dysfunction criterion of the universalist DSM-IV approach and state that external and cultural factors can shape and determine the symptoms associated with psychiatric disorders even when no internal dysfunction is present (Lilienfeld & Marino, 1999
; Wakefield et al., 2002
). Thus, for example, ethnographic vignettes administered to clinicians showed that most clinicians in the study thought that youth reacting to a negative environment vignette that exhibited antisocial behavior but were free of an internal dysfunction were judged not to have a mental disorder in following DSM-IV criteria but were in need of professional treatment (Wakefield et al., 2002
). Thus, whether or not the internal dysfunction is considered an essential criterion for a disorder, clinicians ultimately use their common sense when referring children for treatment.
Relativists like Weisz and colleagues (2006)
question the feasibility of developing a universal classificatory system for all cultures, such as the ICD-10 (WHO, 1992
), since such taxonomies build on the assumption that syndromes or disorders are similar across cultures and what may vary is the manifestation of the symptoms. In fact, relativists claim that culture can shape not only the manifestation and content of symptoms, but the development of the syndrome and symptom cluster per se, a core difference with the universalist approach which claims the role of culture is in shaping the expression of the symptom and the magnitude and intensity of psychosocial risk and protective factors. Thus, some relativistic researchers posit that unless nosological criteria are significantly recast or even derived anew on the basis of culture-specific information, misclassification will continue to occur (Fabrega, 1990
; Hughes, Simons, & Wintrob, 1997
The combined relativistic and universalistic approach in diagnostic classificatory systems for psychopathology states that some disorders (i.e., autism, schizophrenia, fragile X syndrome and other pervasive developmental disorders) are more likely to be universal in all cultures because they are mostly based on neural pathology (Rutter & Nikapota, 2002
). However, other more common disorders, even though they may share a biological or genetic substrate, are more likely to be shaped by social context, cultural norms and developmental stage. Thus, Rutter and Nikapota argue in favor of integrating both a universal and relativistic view of psychopathology depending on the specific disorder. They argue that the extent to which more common specific disorders vary across cultures will depend on the extent to which societies differ in socio-cultural and contextual features that are important in the pathogenesis of the disorder. The key question, as stated by Rutter and Nikapota, is ‘whether the associations with psychosocial functioning or disorder stem from ethnicity, from racial discrimination, from the associated social risks (e.g., poor housing, unemployment, educational disadvantage) or some complex interaction between these variables’ (p. 278).
The debate among investigators and clinicians who adhere to the universalist versus the relativistic approach has had a long history and continues to this date. However, the extent to which the definitions of disorders or syndromes are universal across cultures or vary significantly across cultures is a matter to be determined by empirical inquiry that establishes the validity of the diagnostic criteria across cultures (Rutter & Nikapota, 2002
). In what follows we organize our presentation of empirical evidence in favor of or against the different views based on a modification made by Bird (2002)
of the Robins and Guze (1970)
criteria for determining the validity of the diagnostic criteria cross-culturally. The criteria are the following: 1) clinicians across cultures should describe the problem in children similarly attesting to the face validity of the syndrome or disorder, 2) the risk and protective factors associated with the disorder or syndrome should be similar across cultures, 3) conditions that tend to co-occur with the syndrome or disorder should co-occur across cultures, 4) there should be commonality in the outcomes described for the condition, including laboratory and other biological or neurological tests, and 5) there should be commonality in treatment response. We add to these criteria the need for assessing reliability and validity of the tools or protocols available that measure the diagnostic criteria, an issue that is crucial for estimating cross-cultural validity. Unfortunately a rigorous testing of all these validity criteria has yet to be accomplished for almost all psychiatric disorders within a cultural setting and even less evidence exists across cultural groups particularly for child disorders.