Attention deficit/hyperactivity disorder in primary school children of Tabriz, North-West Iran

Prevalence of attention-deficit hyperactivity disorder in children, adolescents and adults in the Middle East and North Africa region: a systematic review and meta-analysis

OBJECTIVES

To systematically estimate the overall prevalence of attention-deficit hyperactivity disorder (ADHD) in children, adolescents and adults across the Middle East and North Africa (MENA) region.

DESIGN

Systematic review and meta-analysis conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.

DATA SOURCES

Medline and Scopus databases were comprehensively and systematically searched between 1990 and February 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included all cross-sectional or cohort studies that diagnosed ADHD using validated diagnostic tools (eg, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, ADHD rating scales and ADHD diagnostic interview) or non-validated tools (eg, brain imaging techniques, computerised cognitive tests and quantitative electroencephalography).

DATA EXTRACTION AND SYNTHESIS

Two reviewers performed the data extraction independently using standardised data collection sheet. Newcastle-Ottawa Scale was used to assess the quality of the included studies. Individualised and pooled event rate and upper and lower limit at 95% CI were calculated according to the ADHD cases and the total sample size using a random-effect model. The subgroup prevalence analyses according to ADHD subtypes, gender, MENA country and age were also performed.

RESULTS

A total of 63 articles met the inclusion criteria involving 849 902 participants. The overall prevalence of ADHD was 10.3% (95% CI 0.081 to 0.129). The prevalence rate ranged from 1.3% (Yemen) to 22.2% (Iran). Subgroup analyses showed that the prevalence in adults was 13.5 and 10.1 in children and adolescents. Males exhibited significantly higher prevalence compared with females as these were 11.1% and 7%, respectively. Attention-deficit subtype was significantly the most prevalent (46.7%) compared with hyperactivity/impulsivity (33.7%) and combined types (20.6%).

CONCLUSION

The overall prevalence of ADHD was high in the MENA region. It is crucial to allocate more attention and resources towards the prevention and treatment of ADHD in children, adolescents and adults within the region.

Molecular Study of STin2 (Intron 2) Variant of the SLC6A4 Gene in Children and Adolescents with Attention-deficit Hyperactivity Disorder

Background: Attention-deficit hyperactivity disorder (ADHD) is one of the most familiar childhood psychiatric disorders. Various molecular genetic reviews indicate that genes are crucial in susceptibility to ADHD. The serotonin transporter gene (SLC6A4) has polymorphisms that correlate with ADHD. The association between ADHD and SLC6A4 gene variants in the Iranian population has not been investigated yet. Objectives: This study analyzed the STin2 (intron 2) variant of the SLC6A4 gene in Iranian children and adolescents with ADHD. Methods: In this retrospective case-control study, 86 ADHD patients and 99 healthy volunteers aged five to 14 were enrolled as the case and control groups, respectively. The STin2 (intron2) fragment of the SLC6A4 gene was amplified using specific primers by conventional PCR, and three STin2 alleles of the SLC6A4 gene (STin2.9, STin2.10, and STin2.12) were examined using the acrylamide gel method. Results: We found no significant difference between the ADHD and control groups in STin2.9 (34.9% vs. 39.4%, P-value = 0.824), STin2.10 (29.1% vs. 23.2%, P-value = 1.354), and STin2.12 (36% vs. 36.4%, P-value = 0.986) variants. Conclusions: There was no association between the frequency of STin2 variant alleles of the SLC6A4 gene and ADHD, but in the study of risk estimation, allele 10 of this variant was a risk allele in ADHD patients.

Psychometric properties of the Persian version of preschool age psychiatric assessment (PAPA) for attention-deficit/hyperactivity disorder: Based on DSM-5

Childhood and adolescence psychiatric disorders affect subsequent stages; early diagnosis of these disorders, such as attention-deficit/hyperactivity disorder (ADHD), is necessary. There is no reliable and valid diagnostic interview for ADHD in Asian Persian or Farsi speaking countries. The DSM 5-based version of the interview was sent to the 14 child and adolescent and general psychiatrists to ensure the validity of the ADHD section of the PAPA interview through an online website. Out of 59 health centers, 15 centers were selected via systematic random sampling. Three hundred children participated in the study. ADHD questions of the PAPA had the power to differentiate, with a sensitivity of 0.92, a specificity of 0.01. It had positive diagnostic value = 95.83 %, negative diagnostic value = 98.91 %, negative correlation ratio = 0.12, overall diagnostic accuracy = 98.67 % and diagnostic chance ratio = 2085.35. ADHD questions of the PAPA diagnostic interview can diagnose ADHD in preschool as a reliable tool based on DSM-5.

The prevalence of attention deficit hyperactivity disorder in Iran: An updated systematic review

Background: Attention deficit hyperactivity disorder (ADHD) is among the most common neurodevelopmental disorders in children and adolescents. There is a controversy over the true prevalence of ADHD in Iran, the knowledge of which is crucial for allocating health care resources and identifying research priorities. This is an updated systematic review of the prevalence of ADHD in Iranian children and adolescents. Methods: For this systematic review, PubMed/Medline, Web of Science, Scopus, PsycINFO, IranPsych, IranMedex, Irandoc, Google Scholar, and grey literature were reached for publications between January 1990 and December 2018 that reported prevalence estimates of ADHD in Iran. Parallel independent assessments were conducted. The Quality Assessment Checklist for Prevalence Studies was used to assess the overall quality of studies. Results: A total of 34 original studies covering 33 621 Iranian children, adolescents, and adults were included. The included studies were mostly conducted on the population of preschool, elementary, middle, and high school-aged children as well as adolescents. Also, 6 studies addressed university students. Prevalence estimates of ADHD reported varied substantially across the studies and offered a range of heterogeneous data. Conclusion: Overall, making exact comparisons among studies was not easy because the assessment method and the type of sampling could impact prevalence estimates. These factors need to be considered when comparing data from different studies.

Attention Deficit Hyperactivity Disorder Symptoms in Young Children with Autism Spectrum Disorder

The purpose of the current study was to examine the prevalence of attention deficit hyperactivity disorder (ADHD) symptoms among young children with autism spectrum disorder (ASD), child and parent-related demographic and clinical correlates of ADHD symptoms, and the relationships between co-occurring mental health problems and ADHD symptoms. Data for this cross-sectional study came from 979 toddlers and preschoolers, ages 1.5-5 years, with ASD. The primary outcome, ADHD symptoms, was measured using the Child Behavior Check List 1.5-5 (CBCL). Additional information from the medical record included demographics, parenting stress, and Autism Diagnostic Observation Schedule Second Edition. Descriptive and bivariate (ANOVA, Chi-Square) statistics and multivariate, multinomial regression analyses were used to examine demographic and clinical differences between low, moderate, and high ADHD symptom groups, as defined by 2 ADHD-related subscales. There were 418 (43%) children in the low ADHD symptom group, 294 (30%) in the moderate ADHD symptom group, and 267 (27%) in the high ADHD symptom group. Those with high ADHD symptoms were less likely to be Black or Hispanic and less likely to have parents with a graduate-level education compared to those with low ADHD symptoms. Parenting stress and all CBCL DSM-oriented subscales were positively associated with increasing ADHD symptoms. Among young children with ASD, ADHD symptoms were highly prevalent. The presence of ADHD symptoms was associated with increasing parenting stress and greater levels of other psychopathologies. These data suggest that young children with ASD should be evaluated for ADHD, and mental health as a whole. LAY SUMMARY: We investigated attention deficit hyperactivity disorder (ADHD) symptoms in toddlers and preschoolers with autism spectrum disorder (ASD) from a large sample with diverse race and socioeconomic background. In our study, we found that ADHD symptoms are highly prevalent in young children with ASD and are associated with increasing parenting stress and greater level of other psychopathologies, both internalizing and externalizing problems.

DRD4 Gene Polymorphisms as a Risk Factor for Children with Attention Deficit Hyperactivity Disorder in Iranian Population

Background and Objective

Dopamine dysfunction is known to be associated with attention deficit hyperactivity disorder (ADHD). Dopamine D4 receptor gene (DRD4) is one of the important genes in this pathway. This study intended to investigate the variable number of tandem repeats (VNTR) in exon 3 of the DRD4 gene in Iranian children and adolescents.

Materials and Methods

In this study, 130 children with ADHD, aged 6–14 years, and 130 healthy children, within the same age range, were enrolled. All children were selected from northwest of Iran which have Caucasian ethnic background and are of a Turkic ethnic group. VNTR polymorphisms of the DRD4 gene were evaluated by PCR using exon 3-specific primers followed by agarose gel electrophoresis.

Findings

The Hardy-Weinberg principle and Chi-square test showed a significant difference in 4-repetition (4R) alleles between the ADHD (76.2%) and control (53.8%) groups (p = 0.004; X² = 17.39; df = 5). The least percentage of repetition alleles in both groups was 2R.

Conclusion

There is a significant correlation between the 4R alleles of DRD4 and ADHD in the northwest of Iran.

A Randomized Trial of Comparing the Efficacy of Two Neurofeedback Protocols for Treatment of Clinical and Cognitive Symptoms of ADHD: Theta Suppression/Beta Enhancement and Theta Suppression/Alpha Enhancement

Introduction. Neurofeedback (NF) is an adjuvant or alternative therapy for children with Attention Deficit Hyperactivity Disorder (ADHD). This study intended to compare the efficacy of two different NF protocols on clinical and cognitive symptoms of ADHD. Materials and Methods. In this clinical trial, sixty children with ADHD aged 7 to 10 years old were randomly grouped to receive two different NF treatments (theta suppression/beta enhancement protocol and theta suppression/alpha enhancement protocol). Clinical and cognitive assessments were conducted prior to and following the treatment and also after an eight-week follow-up. Results. Both protocols alleviated the symptoms of ADHD in general (p < 0.001), hyperactivity (p < 0.001), inattention (p < 0.001), and omission errors (p < 0.001); however, they did not affect the oppositional and impulsive scales nor commission errors. These effects were maintained after an eight-week intervention-free period. The only significant difference between the two NF protocols was that high-frequency alpha enhancement protocol performed better in suppressing omission errors (p < 0.001). Conclusion. The two NF protocols with theta suppression/beta enhancement and theta suppression/alpha enhancement have considerable and comparable effect on clinical symptoms of ADHD. Alpha enhancement protocol was more effective in suppressing omission errors.

Knowledge and Attitude of Parents of Children With Attention Deficit Hyperactivity Disorder Towards the Illness

Background

The knowledge and attitude of parents about attention deficit hyperactivity disorder (ADHD) is a public health issue in which management and rehabilitation approaches may be influenced.

Objectives

The current study aimed to evaluate the knowledge and attitude of the parents of children with ADHD towards this disorder in Tabriz, Iran.

Materials and Methods

The current cross-sectional study evaluated 295 parents of children and adolescents with ADHD referred to psychiatric clinics of Tabriz University of Medical Sciences. The subjects were diagnosed based on Kiddie schedule for affective disorders and schizophrenia for school-aged children (K-SADS) and recruited according to a convenience sampling method in the first five months of 2014. The parents’ knowledge and attitude towards ADHD was studied by a researcher-made questionnaire.

Results

The overall knowledge of parents was 66% in which 76.72% were aware of related signs and symptoms and 43.38% were able to identify the aberrations. Meanwhile, 44.62% of the parents knew the etiology and 54.75% had information about treatment strategies. In addition, 33.55%, 37.91%, 25.52% were aware of ADHD consequences, diagnosis and prevalence dimensions, respectively. Moreover, 82.72% of the parents had a positive attitude towards ADHD. A positive correlation was found between parents’ attitude towards ADHD and their overall knowledge (identification, etiology, treatment, consequences and prevalence dimensions), ranging from 0.12 to 0.36 (P < 0.50). Age, gender, and place of residence did not have a correlation with parents’ knowledge and attitude towards ADHD. Parent’s education level only had a positive correlation with the knowledge of symptoms, with a value of 0.19 (P < 0.01). Parents with a higher overall knowledge, knowledge of ADHD symptoms, and prevalence rates accepted combination therapy (P < 0.05).

Conclusions

While the overall knowledge of parents regarding ADHD was favorable, they were mostly unable to identify the aberrations in children with ADHD. These results may help practitioners address pitfalls in parent management training programs.

Familial-Environmental Risk Factors in South African Children With Attention-Deficit Hyperactivity Disorder (ADHD): A Case-Control Study

We investigated familial and environmental risk factors in a cohort of South African children diagnosed with attention-deficit hyperactivity disorder (ADHD). A prospective, hospital-based case control study was conducted comprising 50 children diagnosed with ADHD and 50 matched non-ADHD controls. The adjusted effect of familial-environmental risk factors on ADHD was determined by systematic assessment. Birth complications, parental psychiatric disorder, maternal ADHD, early childhood trauma, and nonmaternal child care were significant risk factors for ADHD. Prolonged breastfeeding was found to be protective. In a multivariable logistic regression model, 5 criteria (birth complications, breastfeeding <3 months, at least 1 parent with tertiary education, presence of parental psychiatric disorder, and nonmaternal primary caregiver) differentiated ADHD from non-ADHD controls with a sensitivity and specificity of 74% and 86%, respectively. We found a correlation between certain familial and environmental risk factors and ADHD. A 5-criterion multivariable logistic regression model may offer clinical guidance in ADHD diagnosis.

Effect of adenotonsillectomy on ADHD symptoms of children with adenotonsillar hypertrophy and sleep disordered breathing

BACKGROUND

Adenotonsillar hypertrophy is the most common etiologic agent for the obstruction of the upper airways in children, which might be associated with attention-deficit hyperactivity disorder (ADHD), one of the most common psychiatric disorders of childhood. Despite the concurrence of these two conditions, i.e., obstruction of the airways and ADHD, no exact etiologic relationship has been established between adenotonsillectomy (AT) and ADHD symptoms. This study was undertaken to evaluate the effect of AT on the ADHD symptoms in children with adenotonsillar hypertrophy and sleep disordered breathing (SDB).

METHODS

The design of the present study consisted of pre-test and post-test, followed by post hoc tests. Fifty-three children aged 3-12 were included in this study, selected from those referring to the Pediatric Hospital of Tabriz University of Medical Sciences, with SDB, adenotonsillar hypertrophy and ADHD based on DSM-IV criteria, by availability of the subjects undergoing adenotonsillectomy after evaluation of the severity of ADHD symptoms. The scores of ADHD symptoms were evaluated before AT and at 3- and 6-month postoperative intervals based on Conner's Parent Rating Scale-Revised (CPRS-R) Questionnaire. Repeated-measures ANOVA and Fisher's exact test were used for data analysis.

RESULTS

AT resulted in a significant decrease in the severity of ADHD symptoms (oppositional behavior, cognitive disorders, inattention, hyperactivity and ADHD index) at 3- and 6-month postoperative intervals (P<0.001), with more significant decreases at 6-month postoperative interval compared to 3-month interval (P<0.001).

CONCLUSIONS

Based on the results of this pilot study, AT in children with SDB associated with ADHD resulted in a significant decrease in the severity of ADHD symptoms.

Personality profile of parents of children with attention deficit hyperactivity disorder

Objectives. The present study was carried out aiming to identify the personality profile of parents of children with Attention Deficit Hyperactivity Disorder (ADHD). Methods. This study is of a descriptive, analytic, cross-sectional type in which parents of 6–12-year-old children with ADHD who were referred to the Bozorgmehr Psychiatric Clinic, affiliated with Tabriz University of Medical Sciences, were enrolled. ADHD was diagnosed according to the criteria of DSM-IV-TR and a quasi-structured diagnostic interview (K-SADS-PL). The personality profile of the parents was assessed with the Millon Clinical Multiaxial Inventory-III (MCMI-III). Results. According to the findings of this study, the most common personality problems based on the assessment scales in the MCMI-III belonged to the clinical patterns of depressive personality in 43 persons (25.3%), histrionic personality in 34 persons (20%), and compulsive personality in 29 persons (17.1%). According to discriminant analysis, four scales of somatoform, sadistic, dependence, and though disorder were direct and antisocial scale was reverse significant predictors of membership in the women group. Conclusion. According to the findings of this pilot study, personality disorders are prevalent in parents of ADHD children and mothers suffer from personality disorders more than fathers.

Subcortical encoding of speech cues in children with attention deficit hyperactivity disorder

OBJECTIVE

There is little information about processing of nonspeech and speech stimuli at the subcortical level in individuals with attention deficit hyperactivity disorder (ADHD). The auditory brainstem response (ABR) provides information about the function of the auditory brainstem pathways. We aim to investigate the subcortical function in neural encoding of click and speech stimuli in children with ADHD.

METHODS

The subjects include 50 children with ADHD and 34 typically developing (TD) children between the ages of 8 and 12 years. Click ABR (cABR) and speech ABR (sABR) with 40 ms synthetic /da/ syllable stimulus were recorded.

RESULTS

Latencies of cABR in waves of III and V and duration of V-Vn (P⩽0.027), and latencies of sABR in waves A, D, E, F and O and duration of V-A (P⩽0.034) were significantly longer in children with ADHD than in TD children. There were no apparent differences in components the sustained frequency following response (FFR).

CONCLUSIONS

We conclude that children with ADHD have deficits in temporal neural encoding of both nonspeech and speech stimuli.

SIGNIFICANCE

There is a common dysfunction in the processing of click and speech stimuli at the brainstem level in children with suspected ADHD.

Characteristics of DSM-IV attention deficit hyperactivity disorder combined and predominantly inattentive subtypes in a Turkish clinical sample

Consecutively referred subjects (N = 537) to an outpatient clinic were evaluated to compare the Attention Deficit Hyperactivity Disorder Combined (ADHD-C) and predominantly inattentive (ADHD-PI) subtypes using parent and teacher ratings and neuropsychological variables. Statistical significance was at P < 0.002 adjusted for multiple comparisons. ADHD-PI subjects were older, more likely to be female, higher socioeconomic status, had lower Child Behavior Checklist and Teacher Report Form Aggression, Delinquency and Social Problems scores, and higher Withdrawal and Competence scores, compared to ADHD-C subjects. Comorbid conduct problems were more common among ADHD-C subjects. There were no differences in terms of anxiety/depression, and neuropsychological measures. The study is unique in that it provides data on a broad range of measures from a middle income developing country with important confirmation of similar pattern of differences and similarities between ADHD-C and ADHD-PI subtypes previously reported in North American and Western European samples.

The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review

This article describes a comprehensive meta-analysis that was conducted to estimate the prevalence of attention-deficit/hyperactivity disorder (ADHD), as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). A systematic literature review identified 86 studies of children and adolescents (N = 163,688 individuals) and 11 studies of adults (N = 14,112 individuals) that met inclusion criteria for the meta-analysis, more than half of which were published after the only previous meta-analysis of the prevalence of ADHD was completed. Although prevalence estimates reported by individual studies varied widely, pooled results suggest that the prevalence of DSM-IV ADHD is similar, whether ADHD is defined by parent ratings, teacher ratings, or a best estimate diagnostic procedure in children and adolescents (5.9-7.1 %), or by self-report measures in young adults (5.0 %). Analyses of diagnostic subtypes indicated that the predominantly inattentive type is the most common subtype in the population, but individuals with the combined type are more likely to be referred for clinical services. Additional research is needed to determine the etiology of the higher prevalence of ADHD in males than females and to clarify whether the prevalence of ADHD varies as a function of socioeconomic status or ethnicity. Finally, there were no significant prevalent differences between countries or regions of the world after controlling for differences in the diagnostic algorithms used to define ADHD. These results provide important support for the diagnostic validity of ADHD, and argue against the hypothesis that ADHD is a cultural construct that is restricted to the United States or any other specific culture.

Pregnancy-related maternal risk factors of attention-deficit hyperactivity disorder: a case-control study

Background. The etiology of attention-deficit hyperactivity disorder (ADHD) is complex.This study was conducted to evaluate the pregnancy-related maternal risk factors of ADHD. Methods. 164 ADHD children attending to Child and Adolescent Psychiatric Clinics compared with 166 normal children selected in a random-cluster method from primary schools. ADHD rating scale and clinical interview based on Schedule for Affective disorders and Schizophrenia for School-Aged Children (K-SADS) were used to diagnose ADHD cases and to select the control group. Results. The mean maternal age at pregnancy, duration of pregnancy, and the mean paternal age were alike in two groups. The ADHD children's mothers compared with those of control group had higher frequencies of somatic diseases, psychiatric disorders, and alcohol and cigarette exposure during the pregnancies (P < 0.01). Also birth by cesarean section was more common among mothers of ADHD children (P < 0.001). These factors plus trauma to the abdomen during pregnancy were significantly predictors of ADHD in children. Conclusions. Some pregnancy-related maternal factors may be considered as environmental risk factors for ADHD. Each of these factors considered in our study as a risk factor needs to be tested and confirmed through next methodologically appropriate researches in this field.