Abstract

Objective: Attention Deficit Hyperactivity Disorder (ADHD) in children is often viewed as a result of bad parenting, moral failure, or lack of discipline in many societies (Cueli et al., 2024). This raises the question of whether cultural expectations of child behavior in East Asian societies influence how parents respond to their children diagnosed with ADHD. In this study, we predict that culturally embedded expectations of child behavior significantly influence parental perspectives in child ADHD care. Using existing literature (Lv et al., 2025) this study refers to Eastern Asian culturally embedded expectations of child behavior as including being obedient, listening to adults, conforming to group expectations, showing respect for others and developing useful social skills. For the purposes of this study, parental perspectives in child care are simply defined by what parents think and how they feel about disciplining children with ADHD. Method: We performed a comprehensive review with structured analysis to evaluate recent evidence about parental perspectives in ADHD care. The review included studies published from 2021 to 2025 to guarantee contemporary relevance. Eligible research included peer-reviewed journal articles, systematic reviews, meta-analyses, and narrative reviews; however, theses, conference abstracts, editorials, blogs, grey literature, and books were excluded. The search took place from September 3, 2025, to January 3, 2026, and the main database used was PubMed. Results: Cultural behavioral expectations were under examined, with merely 10.8% of studies specifically evaluating this issue. In the majority of studies (64.9%), parenting style was also not explicitly documented, which suggests a lack of uniformity in its measurement and conceptualization. Cultural behavioral expectations were also under examined, with merely 10.8% of studies specifically evaluating this issue. According to our analysis, there was no significant correlation between cultural expectations and ADHD behavior framing, parenting style or parenting stress. However, we noticed a correlation between cultural expectations and a preference for strict or compliance-focused discipline. The results generally suggest that culturally acceptable child behavior may have a limited but specific impact, especially on punishment, whereas the wider relationships between many aspects of parenting remain unclear. Conclusion: Our results indicate that cultural expectations of normal child behavior and parental perspectives on ADHD care are related in a broad and complicated way. We also observed that limited and inconsistent measurement of cultural variables in the literature makes it difficult to draw definitive conclusions, indicating that current research may not adequately reflect the complexity of these influences.

Keywords

Cultural Behavioral Expectations, ADHD, Parental Perspectives, Parental Stress

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1. Introduction

1.1. Overview of ADHD in East Asia vs Other Parts of the World

Attention deficit/hyperactivity disorder (ADHA) is a complex neurodevelopment condition that is characterized by recurrent patterns of impulsivity, hyperactivity, and inattention (Heng et al., 2025; Liu et al., 2023; Tan et al., 2025). A meta-analysis of studies showed that the global prevalence of ADHD in children is approximately 5% to 8% (Tan et al., 2025) (Ayano et al., 2023). In East Asia, pooled prevalence ranges from 6% - 7%, depending on the different countries (Liu et al., 2018; Bahraini et al., 2024; Chen et al., 2025). Despite the similar symptom profiles, people in East Asian cultures are diagnosed with ADHD later in life compared to Western cultures, because referrals usually only take place when behavioral or academic issues are noticed (Feng et al., 2024; Liu et al., 2024).

In many Western cultures, ADHD is usually conceptualized using a biomedical framework that emphasizes neurodevelopment mechanisms and also evidence-based clinical interventions (Chang et al., 2021; Eom & Kim, 2024). In contrast, studies from East Asian societies suggest that ADHD-related behaviors are commonly viewed through behavioral, moral, or educational lenses, with less attention or impulse control issues being blamed for a lack of discipline or effort (Wong & Wong, 2021). In line with these views, studies suggest that East Asians mediate child care through schools, while Westerners typically involve primary care screening and early parental concern (Wang et al., 2025).

These differences extend to treatment approaches, where families in East Asian regions tend to be less willing to use pharmacological interventions and depend more on behavioral regulation, academic assistance, or family-based strategies compared to Western settings (Fan et al., 2022; Ma et al., 2024; Zhong et al., 2025). East Asians are reluctant due to some of the cultural ideas about health and medicine.

1.1.1. Theories about Culture and Parenting Styles

Culture shapes how ADHD is interpreted and managed within families, influencing whether symptoms are viewed as medical, moral, or disciplinary in nature (Golos et al., 2021). Bronfenbrenner’s Ecological Systems Theory (Muraco et al., 2026; “Ecological Systems Theory”, 2025) proposes a theory that child development is shaped by multiple interacting systems, with culture, values, and social norms and cultural values located within the macrosystem. This suggests that parental reactions are influenced by cultural and social factors rather than being personal decisions (Guy-Evans, 2025, 2024).

The most common types of parenting styles we found include authoritative style, authoritarian style, and permissive styles (Chan et al., 2025; Lin et al., 2025; Lv et al., 2025; Wong & Wong, 2021). Western cultures typically encourage authoritative parenting (warmth, open communication, clear expectations) or permissive parenting (emotional support, few rules), while authoritarian parenting is often discouraged due to links with behavioral problems (Patel et al., 2024; Setyanisa et al., 2022; Lv et al., 2025).

Many East Asian cultures however, are shaped by Confucianism and collectivist values, which emphasize self-regulation, obedience, conformity, and respect for authority (Chan et al., 2025). Parents usually hold higher expectations for children’s behavior, viewing self-discipline and attentiveness as indicators of proper upbringing (Chan et al., 2025; Lansford, 2022; Wong & Wong, 2021). Consequently, ADHD-related behaviors may be interpreted as intentional misbehavior rather than a neurodevelopmental disorder, leading to increased stigma, stress, and delayed diagnosis (Chan et al., 2022a; Gordon & Hinshaw, 2017; Lv et al., 2025; Wong & Wong, 2021; Janssens et al., 2023; Yong et al., 2023).

Cultural norms also affect how parents cope with caregiving challenges and whether they seek professional help (Wang et al., 2025). In many East Asian settings, parents depend on self-regulation, spiritual or religious coping, informal social support, or avoidance strategies when managing ADHD-related challenges. While parenting styles and cultural norms have been thoroughly documented, fewer studies have specifically investigated how parents interpret their children’s behaviors, manage emotional stress and caregiving challenges (Wong & Wong, 2021). This highlights the gap and necessity for research that specifically examines parental perspectives in culturally diverse contexts

1.1.2. Effects of Culture on Parents’ Perspectives

Parents often interpret early ADHD-related behaviors as intentional misconduct rather than neurological symptoms, leading to increased disciplinary strategies over time (Chen et al., 2025). This contributes to parents being criticized for perceived inadequacies, as behavioral issues are interpreted as failures of discipline or moral teaching rather than neurodevelopmental factors.

Social judgment further shapes parental emotions. Parents frequently perceive negative evaluations from others when their children display ADHD symptoms, leading to ‘courtesy stigma’ (stigma by association) and, when internalized, ‘affiliate stigma’—persistent self-blame, increased stress, and emotional burden (Chang et al., 2021; Drent et al., 2022).

Culturally embedded expectations about child behavior, parental responsibility, and obedience intensify experiences and parents are then prone to more pressure to maintain behavioral control (Chan et al., 2025; Chen et al., 2025; Lin et al., 2025). Family-level stress also plays a role; lower family support is associated with less supportive parental responses (Li & Lansford, 2018), and the emotional strain of ADHD caregiving is significant regardless of cultural context (Chan et al., 2022b; MacDonald et al., 2019).

1.1.3. Role of Caregivers in ADHD Care (Why Parenting Perspectives Matter)

Parents play a central role in the diagnosis of ADHD as they are the ones who make most of the decisions regarding recognizing symptoms, seeking professional assistance, and treatment of ADHD (Lu et al., 2022). They act as gatekeepers to care, determining whether behaviors are considered harmful and whether therapeutic routes are followed (Bringer et al., 2025).

In many cases the care process starts with parents gradually noticing abnormal behavioral patterns, followed by consultation with family members or health professionals or eventual referral for diagnosis (Sainsbury et al., 2024). During this period, parents frequently express feelings of being overwhelmed and uncertain about how to optimally support their child, despite a strong desire to secure appropriate care (McLaughlin et al., 2025). When diagnosis is delayed, parents may find it difficult to adjust their parenting strategies, which may lead to ongoing parent-child conflict and worsen ADHD symptoms (Feng et al., 2023).

Most existing research focuses on parenting styles, including permissive, authoritarian, and authoritative, and how they relate to the outcomes of children, parental stress, and the burden of providing care. However, the parents’ comprehension of emotional experiences and reasoning when making decisions about caregiving in particular cultural contexts is not dwelt on. This is especially noticeable in research on ADHD in East Asian societies, which highlights the importance of considering caregiving and parental responsibilities in research.

1.2. Research Gap and the Main Purpose of This Study

Most of the studies in East Asia about ADHD and parenting tend to acknowledge culture as a background setting (Lansford, 2022). Many studies highlight that culture matters (Budman & Maeir, 2022), the impact of Confucian values in parenting (Lee & Kim, 2022), and parents value obedience and discipline (Chan et al., 2025). However, they hardly define directly cultural expectations, link specific expectations or examine how these expectations shape parental response in practice.

Another drawback is that, there is a tendency to treat parenting styles and parental views as the same concept. Most studies focus on categorizing parenting styles, such as authoritarian, authoritative, and permissive (Lo et al., 2025). Less attention is given to parents’ beliefs about ADHD-related behaviors or how they emotionally experience the process of caregiving (Bornstein, 2012) decisions such as when leniency versus consistency is applied, which behaviors are tolerated or punished, and how parents cope emotionally with these decisions (Leitch et al., 2019).

There is a lack of synthesis of shared cultural patterns throughout East Asian contexts, which hinders a comprehensive knowledge of how culturally ingrained expectations function across areas (Chan et al., 2025).

1.2.1. Insufficient Previous Studies

Due to several conceptual and methodological challenges, parental perspectives remain underexplored in ADHD research, particularly in East Asian contexts. Unlike observable behaviors or measurable stress outcomes, parental perspectives involve internal cognitive and emotional processes that are more difficult to define and quantify (Shah et al., 2019). These sensitive processes are often overlooked in biomedical approaches to ADHD that place more emphasis on symptom reduction than on the experiences of caregivers (Patel et al., 2024). As a result, parental perspectives are still not given enough attention in relation to parenting styles and caregiver stress outcomes.

When considered collectively, these gaps highlight the lack of systematic analysis on how culturally embedded expectations of child behavior influence parental interpretations, emotional experiences, and caregiving decisions (Ankori et al., 2025; Lu et al., 2022; Vitulano et al., 2022). Despite the increasing research in how culture shapes parental practices, it is still unclear how parents in East Asian contexts navigate disciplinary decisions and manage the emotional demands (Alrahili et al., 2022; Chawla et al., 2024). It is important to address this gap in order to have a deeper understanding of ADHD care reflecting cultural influences and parental experiences.

1.2.2. Research Question and Hypothesis

Our study aims to fill in the gaps in the literature by investigating how parental perspectives on ADHD care in East Asian societies are influenced by culturally embedded expectations of child behavior. The study specifically answers the following research question: Do East Asian societies’ culturally embedded expectations of child behavior affect how parents perceive ADHD, make decisions about discipline, deal with emotional situations, and respond when their children need help? To address this research question, we predicted the following three questions.

Review Question 1: In East Asian cultural contexts, how is support for culturally embedded expectations (like obedience, conformity, respect) associated with parental itnerpretations of ADHD-related behaviors and preferences for disciplinary measures?

Review Question 2: To what extent is there a preference shown for consistency or strictness (or punitive strategies) associated with enndorsmennt of Cultural expectations and tolerance for ADHD-related behaviors?

Review Question 3: What is the relationship between parenting stress or burnout and support for culturally embedded behavioral expecetations within the context of ADHD?

In order to answer these review questions, this study uses a structured analysis and systematic review of recent literature that looks at parental perspectives in ADHD care in East Asian contexts.

1.3. Significance

1.3.1. Study Significance

This study sheds light on ADHD and parenting literature by treating parental perspectives as its own distinct construct, rather than taking it along with common parenting styles and caregiver stress. Previous research in East Asian contexts has mostly treated culture as just a background factor while parenting styles are the main outcomes.

In contrast, here we consider culture as an active influence for shaping parents’ interpretation, experience, and response to ADHD behaviors, which in turn provides a comprehensive understanding of ADHD care by integrating cultural expectations with parental perspectives

1.3.2. Theoretical Significance

This study expands existing ADHD care by incorporating cultural expectations like social harmony, conformity, obedience, and respect into understanding how parents understand ADHD behaviors and make decisions on discipline. It connects sociocultural perspectives such as responsibility, discipline, and social evaluation to the biomedical models of ADHD, and their influence on parental responses.

By doing this, we challenge the assumption that parental responses to ADHD are just neutral or universally comparable. It also contributes to broader cross-cultural research by demonstrating how these cultural contexts help to shape parental reasoning and emotional experiences, particularly in collectivist societies.

1.3.3. Practical Significance

The purpose of this study is to improve ADHD care in culturally diverse settings. We already see that cultural expectations influence how parents interpret children’s symptoms, which then affects how they view ADHD and go on to seek support. By providing this insight, the findings can support more culturally sensitive clinical communications, parent education programs, and intervention strategies. More understandings may reduce stigma, improve parental engagement, and increase acceptance of recommended treatments.

In addition. This study highlights the importance of addressing parental emotional burden within ADHD support systems. By recognizing these culturally specific expectations, practitioners can design interventions that align with parental beliefs, improving the effectiveness and sustainability of care in East Asian contexts.

Finally, these findings can be helpful beyond just East Asian settings. With the increase in global migrations, Western clinicians are increasingly working with more culturally diverse families. Understanding these culturally shaped parental perspectives can improve cross-cultural communication, reduce misunderstandings, and support more effective care.

2. Method

2.1. Study Design and Overall Approach

In a systematic literature review, we studied how culturally embedded expectations of child behavior influence parental perspectives, disciplinary decision-making, and emotional burden in the care of children diagnosed with ADHD. In order to guarantee an organized and transparent method for study identification, selection, and synthesis, we used the PICOST framework. We compare and contrast Western settings with our primary focus on East Asian cultural contexts.

2.2. Framework and Protocol (PICOST)

We selected the PICOST framework to determine the study design, time frame, outcomes, comparative context, core variables, and population of interest. We chose this framework because it offers a transparent framework for defining important parameters and directing the transparent identification, selection, and synthesis of pertinent research. The PICOST elements used to guide this systematic review are summarized in Table 1 below.

Table 1. PICOST Framework for study selection.

2.3. Population of Interest

Parents and primary caregivers of children with a formal ADHD diagnosis, including biological parents, adoptive parents, and legal guardians directly involved in daily child-rearing and disciplinary decision-making, comprised the main study sample. Only when parental perspectives were clearly articulated or when the findings directly affected caregiving behaviors in the family context did we take into consideration studies that involved instructors. We excluded studies that only focused on the opinions of teachers without connecting them to how they affect parents’ perspectives. The reasoning behind this exclusion was that the review’s main goal was to document family-centered experiences, viewpoints, and decision-making processes, all of which are particularly shaped by the home and caregiving relationships and might not be represented in teacher-only reports. Rather than focusing on the clinical outcomes of children, we focused on the beliefs, interpretations, emotional reactions, and disciplinary approaches of parents. Since the review focused on parental perspectives rather than treatment outcomes specific to developmental stages, we did not place any age restrictions on the children. Studies that looked at the experiences or attitudes of parents were allowed to include children and adolescents. Studies that simply looked at adult ADHD populations without considering the family environment were not taken into account.

2.4. Inclusion Criteria

In addition to topic-specific eligibility criteria, publication-based and geographic parameters were applied to ensure contextual relevance and scientific rigor. Given the emphasis on culturally defined behavioral expectations within collectivist societies, this review focused on East Asian populations, with China serving as the primary reference point to support regional comparison and cultural interpretation.

Only studies published between 2021 and 2025 were included to ensure alignment with the most recent evidence, reflecting current diagnostic frameworks, evolving therapeutic approaches, and increasing awareness of Attention-Deficit/Hyperactivity Disorder (ADHD) within East Asian contexts. Studies were considered eligible if they included children or adolescents (0 - 18 years) with a diagnosis or symptoms of ADHD and reported parental perspectives. Study focus included cultural norms related to obedience, conformity, and behavioral expectations; parental interpretations or perceptions of ADHD-related behaviors; parenting styles and disciplinary practices; arental stress, stigma, or emotional burden and parent-child relationship dynamics in the context of ADHD. Both quantitative and qualitative study designs were included to facilitate a comprehensive analysis of behavioral and psycho-social dimensions relevant to the study objectives. Overlap with exclusion criteria was minimized to ensure clarity and methodological coherence.

2.5. Exclusion Criteria

Since these dissertations, conference abstracts, editorials, commentaries, grey literature, and non-peer-reviewed sources, such as blogs and opinion pieces, generally do not undergo rigorous peer review and may lack the methodological transparency or empirical detail necessary for systematic analysis, we did not include them in the study. Our study concentrates on culturally ingrained expectations of child behavior within Asian, particularly East Asian, contexts; thus, we omitted socio-cultural frameworks and studies undertaken beyond East Asian communities to maintain specificity. Including non-Asian situations may lead to cultural heterogeneity that contradicts the study’s objectives.

Given that our study’s analytical emphasis is on parental interpretations, opinions, and experiences with ADHD care, we excluded articles that failed to present parental data or perspectives. Investigations that focused only on children’s clinical outcomes, teacher evaluations, or neurobiological assessments conducted without parental participation also did not meet the goals of our study. Studies that only looked at adults with ADHD were not included because the stage of development has a big effect on family relationships, parental roles, and cultural expectations of behavior. The idea behind looking at parent-child relationships when the sample is limited to kids and teens makes sense.

2.6. Data Extraction and Coding Procedure

The search was conducted between 3 September 2025 and 3 January 2026 using PubMed as the sole database. PubMed was selected due to its extensive coverage of peer-reviewed literature in the biomedical and psychological sciences, its strong representation of studies from East Asia, and its rigorous indexing standards. The use of a single, well-established database ensured consistency in search procedures and reduced duplication, while access to full-text articles supported systematic synthesis. Pubmed was picked as the sole database because it gives extensive coverage of peer-reviewed biomedical and psychological literature. There was also a substantial number of East Asian studies that applied rigorous indexing standards. For this specific research question—which focuses on ADHD, parenting stress, and discipline, PubMed fully captures the core journals in child psychiatry and developmental pediatrics. While using PyscINFO or Scopus could admittedly be useful in identifying additional culturally focused studies, using a single database allows for a highly consistent and reproducible search protocol. Given that the objective was descriptive rather than an exhaustive meta-analysis, a more focused approach would be sufficient. Nevertheless, future reviews can expand their search to multiple databases to increase the scope of material.

To mitigate this limitation, a comprehensive and iterative search strategy was employed. The initial search was deliberately broad, utilizing PMC full-text search terms to maximize sensitivity. Both keyword variations and Medical Subject Headings (MeSH) were applied, including terms such as “ADHD,” “parenting styles,” “cultural expectations,” “East Asian contexts,” and “parental perspectives.” Searches were subsequently refined using Boolean operators (AND, OR) to combine key concepts and improve specificity. For example: (“parent experiences” OR “parental challenges” OR “family functioning”) AND ADHD AND (qualitative OR interview OR “framework analysis” OR thematic). Filters were applied to restrict results to open-access, full-text articles published between 2021 and 2025.

Additionally, reference list screening was conducted to identify further relevant studies. Predefined inclusion and exclusion criteria were consistently applied during screening to enhance methodological rigor, reduce bias, and ensure comprehensive coverage. The full search strategy is provided in Appendix A. The initial search yielded 8,226 records; after removal of duplicates (n = 95), 8,131 records remained for further screening.

2.7. Study Selection Process

The study selection process followed PRISMA 2020 guidelines and is illustrated in Figure 1, which presents the PRISMA flow (Page et al., 2021) diagram of the study selection process.

Title/abstract and full‑text screening were conducted independently by three reviewers (M.W.V.; J.J.D. and P.A.B). Disagreements were resolved through discussion with a fourth reviewer (C.J.). Data extraction was performed by two reviewer (M.W.V. and J.J.D) and verified by a second (C.J.).”

The first records we found through database searching were 8226 in total. Titles and abstracts were used to screen 8131 studies after we removed studies that were duplicated (n = 95). 8032 of these were disqualified because they did not fit the requirements for inclusion. 99 full-text articles were evaluated for eligibility; 62 were eliminated because they were not conducted in East Asian populations (n = 59), had no parental data (n = 1), or were not thematically relevant enough (n = 2). In the end, the final analysis contained 37 studies.

The second stage involved full-text screening of studies for eligibility based on subject relevance, methodological quality, and geographic focus. All studies were assessed against predefined inclusion criteria, and any disagreements were resolved through discussion to ensure consistency. Since our main aim was a descriptive rather than a formal meta-analysis, no formal quality appraisal or risk-of-bias tool was applied. We retained all the peer-review studies that met the criteria.

Figure 1. PRISMA 2020 flow diagram of study selection process.

Data extraction was conducted using a structured coding matrix in SPSS, allowing studies to be systematically organized by region (e.g., East Asia, Central Asia, South Asia) and thematic domains aligned with the conceptual framework. Because this was a descriptive synthesis of existing literature, only descriptive frequency analyses were performed to calculate percentage of studies that fell into each coding category. To facilitate consistent cross-study comparison, qualitative findings were transformed into standardized numerical codes using a three-point scale: 0 = not examined, 1 = mentioned, and 2 = clearly or explicitly analyzed. No inferential statistical tests (e.g. chi-square, Fisher’s exact, correlation, regression) were conducted

Several key domains were coded. The ADHD interpretation domain captured how parents conceptualized ADHD-related behaviors, including whether interpretations were discussed superficially or examined as a distinct analytical component. The discipline domain assessed the extent to which studies addressed strict, compliance-oriented, or authoritarian parenting practices. The parental flexibility domain examined tolerance, adaptability, and challenges in accommodating children’s behavioral symptoms. The punitive discipline domain focused on the use of punishment-based or corrective disciplinary strategies. The parent stress domain evaluated emotional burden, including caregiver strain and psychological stress, distinguishing between general mentions and formal measurement. Finally, the stigma and shame domain assessed parental experiences of social stigma, perceived criticism, and concerns related to cultural expectations and family reputation.

3. Results

3.1. Coverage of Key Domains across Studies

A total of 37 studies were included in the analysis. Rather than evaluating studies based on levels of support, the review examined how extensively each study addressed key domains related to parental perspectives in ADHD care. Overall, most studies focused on a limited number of domains, with relatively few examining multiple aspects simultaneously. Many studies addressed only one or two areas, such as parenting stress or discipline strategies, while comprehensive coverage of cultural expectations, emotional burden, and decision-making processes was less common. This pattern suggests that the existing literature is fragmented, with limited integration of key variables within individual studies. As a result, it remains difficult to draw broad conclusions about how these factors interact in shaping parental perspectives.

3.2. Parenting Style

This part shows how the different studies reported different parenting approaches. In this analysis of parenting style, we aimed to ascertain the prevalence of various parental methods, including authoritarian, authoritative, and mixed styles, within the existing literature. Due to variations in reporting among research, our study concentrates on the existence and classification of parenting styles. Table 2 shows how the different research (n = 37) used different parenting approaches.

Parenting style was not explicitly reported in the majority of studies (64.9%, n = 24). Among the studies that did report parenting style, mixed or non-standard approaches were the most common (24.3%, n = 9). Authoritarian parenting was reported in a small number of studies (8.1%, n = 3), while authoritative parenting was least frequently identified (2.7%, n = 1). Overall, these findings indicate inconsistency in how parenting styles are defined and reported across studies. The high proportion of studies that did not specify a parenting style suggests a lack of standardized measurement or emphasis on parenting frameworks within the literature.

Table 2. Distribution of parenting styles across included studies (n = 37).

3.3. Cultural Expectation

We found cultural expectations about parenting and how children should act in the 37 studies we looked at, but the level of reporting was very different in each case. Many studies precisely highlighted culturally embedded expectations, including obedience, academic success, respect for authority, and behavioral conformity, whereas others failed to provide clear definitions of cultural notions. Descriptive analysis indicated that cultural expectations were not investigated in the majority of studies (67.6%, n = 25). A lesser fraction of research made descriptive reference to cultural expectations (21.6%, n = 8), whereas only 10.8% (n = 4) specifically explored cultural expectations as a major analytical variable. Figure 2 shows these results.

Figure 2. Distribution of studies examining cultural expectations in parenting (n= 37).

Patterns between Cultural Expectations and ADHD-Related Factors

A descriptive comparison was conducted to explore how studies that examined cultural expectations also reported on other ADHD-related variables.

Among the four studies that explicitly examined cultural expectations, two also reported the use of strict or compliance-oriented discipline. In contrast, among the 25 studies that did not examine cultural expectations, only a small number reported similar disciplinary approaches.

3.4. Discipline Strategies

This section builds on what we learned about cultural expectations by looking at how often discipline strategies, especially strict/compliance-oriented and punitive ones, were reported in the research we included. Descriptive analysis indicated that the majority of research did not specifically investigate the preference for strict or compliance-oriented punishment (81.1%, n = 30). A lesser percentage of studies (18.9%, n = 7) offered descriptive references to these disciplinary methods, and none of the studies delivered actual measurements of this variable. Figure 3 shows these results.

Figure 3. Descriptive analysis (discipline strategy).

As a general rule, this means that harsh or compliance-based punishment fits with cultural expectations of following rules and fitting in, though this topic has not been looked into enough in recent research.

Across the included studies, there was no consistent pattern in the relationship between cultural expectations (e.g., obedience and conformity) and disciplinary approaches. Among studies that examined cultural expectations, some reported the use of strict or compliance-oriented discipline, while others did not. Similarly, the use of punitive or corrective disciplinary strategies varied across studies, with no clear or uniform trend emerging.

Overall, these findings suggest that the relationship between cultural expectations and disciplinary strategies is not consistent across the literature. While some studies indicate a tendency toward stricter or more punitive approaches in contexts emphasizing obedience and conformity, others do not support this pattern. This variability highlights the influence of additional contextual factors, suggesting that cultural expectations alone may not directly determine parenting practices in the context of ADHD.

These results suggest that the link between cultural norms and disciplinary actions may be more complicated than just a two-way relationship. Cultural values may affect how discipline is handled in an indirect way, such as through stress on parents, how people see children’s behavior, or stress in the caregiving setting. Also, it may have been hard to find consistent patterns across studies because the ways that disciplinary strategies were defined and measured were different in different studies. Because of this, we have a better understanding of how cultural expectations and disciplinary approaches are related. They are not one-dimensional and depend on the situation.

3.5. Emotional Burden

This section evaluates how the 37 studies we included addressed emotional burden variables, particularly parenting stress or burnout and parental stigma or shame. Descriptive analysis shows that parenting stress or burnout was discussed more frequently in the literature than other emotional burden variables. Although many studies referred to parenting stress in descriptive or experimental contexts, a considerable number did not directly measure or formally assess this variable. By comparison, parental stigma or shame appeared less consistently across the studies. A few number of investigations provided empirical examination of this factor, and many relied primarily on descriptive discussion rather than systematic measurement. These findings suggest that while emotional burden is widely acknowledged in ADHD-related research, it is not consistently operationalized or quantitatively examined. This indicates a gap in the comprehensive evaluation of parental psychological experiences in ADHD contexts. Our findings indicate that although emotional load is recognized in the literature, it is not systematically or consistently quantified, revealing a deficiency in the thorough evaluation of parental psychological experiences in ADHD-related circumstances.

Of the 37 included studies, 26 reported on parenting stress or burnout, whereas fewer studies addressed parental stigma or shame. Across the literature, emotional burden was a commonly examined outcome, particularly in relation to caregiving demands and behavioral management challenges associated with ADHD. However, the relationship between cultural expectations (e.g., obedience and conformity) and these psychological outcomes was not consistently examined. While some studies explored how cultural norms may shape parental stress or experiences of stigma, others did not address this relationship directly.

Overall, the findings suggest that although parenting stress and, to a lesser extent, stigma are important themes within the literature, there is no clear or consistent evidence linking these outcomes to cultural expectations across studies. This variability indicates that additional contextual and familial factors likely influence parental emotional experiences in the context of ADHD. Our findings indicate that, whereas cultural norms of obedience and conformity may influence parental experiences, they do not seem to directly influence emotional load outcomes in the present sample. This reinforces the notion that emotional burden is shaped by various interacting elements, rather than alone by societal expectations.

3.6. Overall Summary of Findings

Across the studies reviewed, parenting styles were most frequently described as mixed or non-standardized rather than fitting into a single, clearly defined category. Many studies reported the use of multiple parenting approaches within the same family context, which contributed to a higher proportion of studies classified under “mixed/other.” Notably, approximately 67.6% of studies did not examine cultural expectations as an explicit analytical variable, while only 10.8% treated cultural expectations as a primary focus of investigation.

Few studies explored disciplinary strategies in relation to cultural expectations, and among those that did, findings were inconsistent. While some studies suggested a tendency toward stricter or more compliance-oriented approaches in contexts emphasizing obedience and conformity, others did not observe this pattern. Similarly, relationships between cultural expectations and other ADHD-related factors such as parenting styles, parental perceptions, and emotional burden, were not consistently addressed across the literature.

In general, disciplinary approaches were underexplored, with approximately 81% of studies not examining this domain in detail. Emotional burden, including parenting stress and stigma, was more commonly discussed; however, its relationship with cultural expectations was not systematically investigated. This suggests that parental emotional outcomes may be shaped by a broader set of influences, including socioeconomic conditions, access to healthcare, and family dynamics, rather than cultural norms alone.

Overall, the findings highlight a persistent gap in the literature. Although there is increasing attention to parental perspectives in the context of ADHD, relatively few studies provide a comprehensive examination of how cultural expectations interact with parenting practices and psychological experiences. Further research is needed to develop a more nuanced understanding of parents’ experiences in raising children with ADHD, particularly within diverse cultural contexts.

4. Discussion

4.1. Overview of the Study and Key Findings

In this study, we examine how culturally embedded expectations of child behaviour influence parental perspectives in ADHD care across East Asian contexts. We observed 37 studies that focused on key aspects such as parenting styles, cultural expectations, discipline strategies, and emotional burden. Overall, we observed that despite inconsistent supporting evidence, parental perspectives may be associated with cultural norms, but these relationships aren’t always properly studied and defined in most current literature. Most focused on parenting stress and emotional burden while other factors such as stigma, shame, and cultural expectations were less systematically analysed. Several factors explain the gap: cultural expectations are often implied rather than explicitly measured; parenting styles and emotional outcomes lack standardized definitions, limiting cross-study comparison; and ADHD parenting is shaped by multiple factors (socioeconomic conditions, healthcare access, family dynamics), making it difficult to isolate culture’s specific role. Importantly, the absence of consistent findings does not mean no relationship exists—rather, current research methods may not fully capture the complexity of parental perspectives in ADHD care.

4.2. Parenting Style: Conceptual Limitations and Cultural Misalignment

Our study revealed unexpected results, including failures to report and inconsistent use of the parenting style variable. Parenting style was not precisely defined or measured in the majority of studies. Definitions and classifications varied even when they did. Particularly in cross-cultural research, this raises questions about the efficacy of contemporary parenting frameworks. Western contexts, where parenting is categorized into authoritarian, authoritative, and permissive styles, are the primary source of foundational research on parenting styles. Although they may not adequately convey the complexities of parenting in non-Western cultures, these categories can still be useful.

In many parts of the West, people think that authoritarian parenting is too strict or controlling. In some Asian cultures, however, similar ways of disciplining may be seen differently. They can be seen as signs of a parent’s love, responsibility, and commitment to their child’s future success (Zhang et al., 2025). Research on parenting often depends on Western ideas about different ways to raise children. When these frameworks are utilized in non-Western contexts without cultural adaptation, they may result in erroneous interpretations. To understand how parents act, you need to pay attention to the cultural values, expectations, and social norms that shape how they do things. Studies aim to link parenting styles to factors such as emotional burden and disciplinary methods, though it’s challenging since parenting styles are measured differently across studies and lack clear, standardized definitions.

4.3. Cultural Expectations and Discipline

Our research shows that cultural expectations appear to play a potentially significant part of our framework. They are not many studies on cultural expectations, so clearly there are some limitations and a need for more research. Usually factors like cultural expectations are difficult to measure because they aren’t just ideas that act on their own and they are usually part of a bigger ideas like beliefs of parenting, discipline, and social norms (Chung et al., 2023; Lin et al., 2025; Abu Alhommos et al., 2022). As a result, some of the presence might be overlooked. In collectivist societies, rules, respecting authority, and cooperation with others are placed very highly (Yildiz et al., 2025). Impulsiveness. and hyperactive behavior, which are usually linked to ADHD are usually bad because they go against what is considered normal in society (Choksomngam et al., 2022). To keep the discipline, some parents might take harsher measures (Chou et al., 2021).

Discipline has been extensively studied in parenting research, with numerous studies investigating parental responses to children with ADHD (Lee & Kim, 2022; Wijerathna et al., 2023; Alenezi et al., 2024). However, the findings of this review suggest that such studies are infrequently contextualized within wider parental or cultural frameworks. Many studies look at disciplinary practices on their own or as part of a general parenting framework, rather than as part of a larger system of cultural beliefs and expectations. As a result, interpreting new findings becomes difficult, since disciplinary practices are often examined without considering the broader cultural context in which they occur.

Overall, these findings suggest that even though there might be a contribution of cultural expectations to stricter disciplinary approaches, the relationship is complexed usually depends on the context and can only be fully explained by further research to examine this relationship more systematically.

4.4. Emotional Burden and Stigma

These results indicate that emotional burden is a significant aspect of the experience of parents in ADHD care. In most studies, the frequent discussion of parenting stress and burnout suggests that managing ADHD-related behaviors place considerable emotional toll on caregivers.

In contrast, there’s less consistent examination of shame and stigma. Most only went to the extent of describing the experience of factors such as social judgment, self-blame, and embarrassment, rather than systematically analyzing them. This suggests that the emotional impact of stigma may be underrepresented in most literature.

Cultural expectations may also play a role in shaping these experiences. Most Asian contexts, there is strong emphasis on what kind of child behavior is considered appropriate for a family’s reputation. This may increase parental sensitivity to social judgment, and as a result, parents may experience greater pressure to manage their child’s behavior in ways that adhere to societal pressures and expectations

However, emotional burdens can also be influenced by multiple factors such as family support, access to healthcare, and individual coping strategies. These may all contribute to parental stress and emotional experiences.

4.5. Strengths and Limitations of the Study

This study has several strengths. First, there is a structured collection and synthesis of recent literature (2021-2025), ensuring that the findings are the most up to date and can reflect the current perspectives of ADHD parenting in Asian contexts. By focusing mainly on these perspectives, we addressed an undervalued area that has limited research.

Second, using PICOST helps to narrow down our inclusion and exclusion criteria and enhances the transparency and consistency of the entire process. The inclusion of both qualitative and quantitative studies helped to provide a more comprehensive understanding of parental experiences.

However, we do have to acknowledge the limitations. One was that this review relied on one database (PubMed), which now excludes other relevant sources in other databases such as PsycINFO, Scopus, or regional sources, thus giving us less diversity of perspectives to analyze.

In addition, most analyzed studies did not explicitly examine cultural expectations as the main primary variable which resulted in interpretations regarding the role of culture to be limited. Another limitation relates to variability in how some of our key variables such as parenting style, discipline strategies, and emotional burden were defined and measured. This inconsistency reduces compatibility and created difficulties in drawing conclusions. Finally, as this study is based on a systematic review design, it relies on quality and scope of existing research. The absence of consistent findings across reflects limitations in literature rather than complete absence

4.6. Implications and Future Directions

Our findings have important implications for both research and practical applications. First, it highlights the need for future studies to examine cultural expectations as the main variable rather than treating it as a background favor. Our understanding of the role of these factors can only be further developed by examining and defining these measures of cultural expectations more consistently and clearly. Second, more emphasis should be placed on parental perspectives, especially in terms of child behavioral interpretations, disciplinary decision-making, and managing emotional challenges. This would require focusing on areas such as parental styles and caregiving stress which go beyond traditional research and foster better understanding.

Third there is need for more culturally sensitive research. Interventions and support systems are the and support systems should keep in mind the cultural values and how they shape the reactions of parents, This could improve communication between clinicians and families, increase acceptance of treatment, and reduce barriers to care. In addition, there needs to be better methodological consistency, by creating standardization of definitions and measurements for variables such as parenting style, emotional burden, and discipline strategies would increase comparability and strengthen the evidence base.

Overall, this study emphasizes that parental perspectives in ADHD care are complex and are an intricate mix of cultural, emotional, and contextual factors. More integrated and culturally informed approaches will help more families to better understand and manage ADHD in diverse settings.

5. Conclusion

ADHD is a widely researched condition that most researchers and medical professionals are focusing on recently. Most of them focus on the treatment and how to make life better for those who are diagnosed with it. However, the aspect of cultural influence on ADHD care is hardly looked at. Though medical treatment is important, the emotional impact of ADHD is great and should be focused on, too. Emotional impact might be greatly shaped by cultural expectations. Hence our study examines how the cultural expectations of a child’s behavior could influence parental perspectives in ADHD care in East Asian cultural contexts.

Overall, these findings suggest that while these expectations may influence how parents respond and interpret ADHD related behaviors, these are not consistently examined. An acknowledgment of parenting stress and emotional burden is present but stigma, cultural expectations, and help seeking behaviors aren’t adequately explored in the same framework.

This review also demonstrates that the common frameworks generally used may not fully capture the culturally specific parenting practices in East Asian contexts; rather, this highlights the need for more context-sensitive approaches that will show the realities of caregiving in diverse cultures in a deeper light. The last, most important note is that the study mostly emphasizes that there are only fragments of information that we get from the studies and hardly provides an integrated understanding of how cultural expectations, emotional burden, and decision-making processes interact. In conclusion, a more culturally informed approach is critical to improve understanding, reduce stigma, and support families managing ADHD in diverse contexts.

Acknowledgements

I would like to appreciate my university, Zhejiang Chinese Medical University, for the opportunity to study and for making this thesis possible. I hope that this work will contribute to the Pediatrics Department, particularly in the area of working with children with ADHD. I would like to especially acknowledge my professor Dr Jiang Chunming, for allowing me to explore different departments, topics, and studies, for not limiting me in my academic pursuits, and also for his mentorship during this study.

My heartfelt appreciation goes to the teams I had the privilege of working with at the Hangzhou first people’s hospital. Thank you to the Pediatrics Team, my main department, for their support. I am also grateful to the collaborative joint departments, including Ultrasound, Radiology, and especially the Behavioral Department and Psychology Department, of Hangzhou first people’s hospital for allowing me to learn from them and for their invaluable contributions to this research. I am grateful to my family and friends for the emotional and moral support and for their provision during this journey. Thank you all for your contributions and support.

List of Abbreviations

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References