Attention deficit hyperactivity disorder: a neglected issue in the developing world

Meta-Analysis: Prevalence of Youth Mental Disorders in Sub-Saharan Africa

Youth in sub-Saharan Africa (SSA) face limited access to professional mental health resources. A comprehensive assessment of the prevalence of mental disorders would build an understanding of the scope of the need. We conducted systematic searches in PsycInfo, Pubmed, AfriBib and Africa Journals Online to identify prevalence rates for five disorders (anxiety, depression, conduct disorder, attention problems and post-traumatic stress) among SSA youth with a mean age of less than 19 years. We calculated a random-effects pooled prevalence for each disorder and assessed possible moderators. The meta-analysis included 63 studies with 55,071 participants. We found the following pooled prevalence rates: 12.53% post-traumatic stress disorder (PTSD), 15.27% depression, 6.55% attention-deficit hyperactivity disorder, 11.78% anxiety and 9.76% conduct disorder. We found high heterogeneity across the studies, which may have resulted from differences in samples or measurement tools. Reported prevalence rates were not explained by the sample (i.e., special or general population), but whether the psychometric tool was validated for SSA youth affected the reported prevalence of PTSD and anxiety. In a meta-regression, prevalence rates were associated with the disorder type, with a higher prevalence of depression and PTSD. We found the mean age significantly moderated the prevalence in univariate meta-regression, with increased age correlated with greater prevalence. Our findings suggest there is a need to explore reasons for varying prevalence rates further and to develop interventions that support youth mental health in SSA, particularly interventions for depression and PTSD. Limitations included a lack of standardization in psychometric tools and limited reporting on research methods, which influenced quality rating. Importantly, the search only considered studies published in English and was conducted 2 years ago. Although recent estimates reported slightly higher than our prevalence estimates, these reviews together highlight the prevalence and importance of youth mental health difficulties in SSA.

Safety and effectiveness of methylphenidate ER multi-unit pellet system in ADHD patients: An open label study

Background

Attention deficit hyperactive disorder (ADHD) is a neurodevelopmental disorder occurring in children and adults. Pharmacotherapy remains the cornerstone of ADHD treatment. Stimulants such as methylphenidate are effective and have been one of the best studied and most frequently used treatment for ADHD. However, different delivery mechanisms and devices may potentially impact patient experience and real-life outcomes.

Aim

This study evaluated the effectiveness of Multiple-Unit Pellet System Delivered Extended-Release Methylphenidate (Contramyl XR) on symptom control and reported outcomes in ADHD patients, in a real-world setting.

Setting

A phase IV, open label, flexible dose, prospective, observational study conducted at six sites covering five provinces of South Africa.

Methods

About 119 participants with ADHD (both newly diagnosed [treatment-naïve] and methylphenidate-treated [switch-over] patients) were enrolled and initiated either on Contramyl XR or switched over from methylphenidate to Contramyl XR. Primary efficacy was assessed by Weiss Functional Impairment Rating Scale (WFIRS) over 12 weeks.

Results

In all, 117 participants completed the study (treatment-naïve patients: 46% [n = 55] and switch-over patients: 54% [n = 64]). Mean change from baseline in total WFIRS (95% confidence interval) was -17.7 (-21.1, -14.3; p < 0.001) at week 4 and -29.3 (-33.5, -25.2; p < 0.001) at week 12. At week 12, there was significant improvement in WFIRS scores, with treatment satisfaction reported by treatment-naïve patients. Switch-over patients also demonstrated comparable effectiveness.

Conclusion

Contramyl XR was found to be clinically effective either as de novo or as switch therapy. It was well tolerated, and all patients chose to continue with the treatment option.

Contribution

Despite distinct and different delivery mechanism of Contramyl XR, this study provides evidence for using it as an alternate treatment option versus reference methylphenidate, in both treatment-naïve and switch-over ADHD patients. Study participants willingness to continue Contramyl XR therapy post study, further strengthens the confidence on the effectiveness of Contramyl XR in managing ADHD patients.

Magnitude, relationship and determinants of attention deficit hyperactivity disorder and depression among University of Gondar undergraduate students, Northwest Ethiopia, 2022: Non-recursive structural equation modeling

BACKGROUND

Up to 80% of adults with attention deficit hyperactivity disorder (ADHD) may have a concomitant psychiatric disorder. ADHD and depression, combined with the demands of University life, can pose serious challenges for students. However, there are limited studies conducted on this topic in our country. Therefore, the current study assessed the magnitude, relationship, and determinants of ADHD and depressive symptoms among students at the University of Gondar.

METHOD

An institution-based cross-sectional study was employed among 1514 undergraduate students at the University of Gondar from June 1-20, 2022. A stratified, simple random sampling technique was applied. Structural equation modeling was employed. The degree of relationship was interpreted based on the adjusted regression coefficient with 95% confidence interval (CI) and p-value (<0.05).

RESULT

In our study, 37.6% [CI: 35.2-40.1%] and 20.01% [CI: 18.1-22.1%] of the participants had depressive and ADHD symptoms, respectively. Chronic illness [β = 0.19, CI; 0.09, 0.30], alcohol use [β = 0.10, CI; 0.03, 0.17], social support [β = -0.23, CI; -0.29, -0.17], problematic internet use (PIU) [β = 0.23, CI; 0.18, 0.27], and insomnia [β = 0.24, CI; 0.17, 0.30] had a direct relationship with depressive symptoms. Mother education level [β = -0.09, CI; -0.13, -0.06], birth order [β = -0.09, CI; -0.11, -0.07], chat chewing [β = 0.18, CI; 0.06, 0.30], and depressive symptoms [β = 0.73, CI; 0.62, 0.86] had a direct relationship with ADHD. Chronic illness [β = 0.14, CI; 0.06, 0.22], PIU [β = 0.16, CI; 0.13, 0.21], social support [β = -0.16, CI; -0.22, -0.12], and insomnia [β = 0.17, CI; 0.13, 0.23] had an indirect effect on ADHD.

CONCLUSION AND RECOMMENDATION

The prevalence of ADHD and depressive symptoms was high. Chronic disease, alcohol use, social support, PIU, and insomnia had a direct effect on depressive symptoms and an indirect effect on ADHD. Mother education, birth order, chat chewing, and depressive symptoms had a direct effect on ADHD. Our study provided useful clues for clinical treatment and school-based interventions that aim to improve college students' mental well-being. It is better to design school-based intervention and prevention programs to achieve timely diagnosis and treatment of these disorders among university students.

Attention Deficit Hyperactivity Disorder (ADHD) among elementary students in rural China: Prevalence, correlates, and consequences

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a widely recognized mental health problem in developed countries but remains under-investigated in developing settings. This study examines the prevalence, correlates, and consequences of ADHD symptoms among elementary school students in rural China.

METHODS

Cross-sectional data were collected from 6,719 students across 120 rural primary schools in China on ADHD symptoms, demographic characteristics, and academic performance in reading and math. ADHD symptoms were evaluated using the caregiver-reported ADHD Rating Scale-IV.

RESULTS

The prevalence of ADHD symptoms was 7.5% in our sample. Male students, students in lower grade levels, and students with lower cognitive ability showed a significantly higher prevalence of ADHD symptoms (ORs = 2.56, 2.06, and 1.84, respectively; p<0.05). Left-behind children showed a significantly lower prevalence of ADHD symptoms than did children who were living with their parents (OR = 0.74, p < 0.05). Adjusted regressions show that students with ADHD symptoms scored 0.12 standardized deviations lower in reading (p < 0.05) and 0.19 standardized deviations lower in math (p < 0.01).

LIMITATIONS

The ADHD Rating Scale-IV is a screening scale rather than a diagnostic test. Caregiver self-report measures also may underestimate ADHD symptoms for our sample.

CONCLUSIONS

ADHD is a common disorder among rural students in China and appears to be contributing to poor academic outcomes. The higher prevalence of ADHD among students with low cognitive ability also suggests that many rural children in China face multifactorial learning challenges. Taken together, the findings indicate a need for educators and policymakers in rural China to develop programs to reduce risk and support students with ADHD symptoms.

Assessing early child development and its association with stunting and schistosome infections in rural Zimbabwean children using the Griffiths Scales of Child Development

There is a paucity of reference early childhood development (ECD) data at community level in rural Africa. Our objective was to conduct a comprehensive assessment of ECD in rural Zimbabwe and determine the impact of stunting and schistosome infections on ECD. Using the Griffiths Scales of Child Development, we conducted a cross sectional assessment of Eye and Hand Coordination (EHC), Personal-Social-Emotional (PSE), Language and Communication (LC), Foundations of Learning (FL) and Gross Motor (GM) domains and the summary General Development (GD) in 166 children aged 6-72 months. The effects of stunting, malnutrition and Schistosoma haematobium infection on ECD was determined. The impact of praziquantel curative treatment of schistosome infection on the developmental scores was determined through a longitudinal follow up at 6 and 12 months. From an initial 166 children, 11 were found to have developmental deficits warranting further investigation. Of the remaining 155, 58.7% recorded a good (≥ average) score for the overall General Development (GD). Proportions of children scoring above the cut-off (≥ average) for each domain were GM (84.5%), PSE (80.6%), EHC (61.9%), FL (43.9%) and LC (44.5%). The prevalence of stunting was 26.8% (95% CI = 20.1%-34.8%) Scores for stunted children were significantly lower for EHC (p = 0.0042), GM (p = 0.0099), and GD (p = 0.0014) with the fraction of lower scores attributable to stunting being GM = 63.4%, GD = 46.6%, EHC = 45%, and LC = 21%. S. haematobium infection prevalence was 39.7% and mean infection intensity was 5.4 eggs/10 ml urine. Infected children had poorer cognitive performance scores for the FL (p = 0.0005) with 30.8% of poor FL attributable to the infection. Performance in all domains improved to the expected normal or above reference levels at 6 and 12 months post curative treatment of schistosome infections. Our study documented reference values for ECD in rural Zimbabwean children. The study detected deficiencies in the FL domain, which were more pronounced in children, infected with schistosomes, highlighting the need for provision of cognitive stimulation tools and access to early childhood foundation education. There is also need for improved child nutrition and treatment of schistosome infections to improve child development outcomes.

Attention Deficit Hyperactivity Disorder (ADHD) among Children Aged 6 to 17 Years Old Living in Girja District, Rural Ethiopia

Objective

Attention deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in childhood with long-term outcomes. Although ADHD is the most studied behavioral disorders of childhood in developed countries, few studies have been conducted in Ethiopia. The aim of this study was to determine the prevalence of ADHD in rural parts of Ethiopia.

Method

A cross-sectional study was conducted from May to June 2015 among children aged 6 to 17 years living in rural areas. A multistage cluster sampling technique was used to select 1302 participants. The Disruptive Behavior Disorder Rating Scale was used to collect the data. Logistic regression analysis was used to see statistically significant variables.

Result

The prevalence rate of attention deficit hyperactivity disorder (ADHD) among children was 7.3%. Being male (Adjusted Odds Ratio (AOR) = 1.81, 95% CI: (1.13, 2.91)); living with a single parent (AOR = 5.0, 95% CI: (2.35, 10.65)); child birth order/rank (AOR = 2.35, 95% CI: (1.30, 4.25)); and low family socioeconomic status (AOR = 2.43, 95% CI: (1.29, 4.59)) were significantly associated with ADHD.

Conclusion

The ADHD prevalence rate was found to be similar with global reports. Prevention and early management of maternal complications is important to reduce the prevalence of ADHD among children.

Prevalence of behavioral disorders and attention deficit/hyperactive disorder among school going children in Southwestern Uganda

BACKGROUND

Disruptive Behavioral Disorders (DBDs) and Attention Deficit/Hyperactivity Disorder (ADHD) are chronic, impairing, and costly child and adolescent mental health challenges which, when untreated, can result in disruptions in school performance, friendships and family relations. Yet, there is dearth of prevalence data on child and adolescent behavioral challenges within sub-Saharan Africa, including Uganda. This study aims to estimate the prevalence rate of behavioral challenges and ADHD among young school going children and early adolescents (ages 8-13 at study enrollment), utilizing a school-based sample in southwest Uganda.

METHODS

We present screening results from a 5-year scale-up study titled SMART Africa-Uganda (2016-2021), set across 30 public primary schools located in the greater Masaka region in Uganda, a region heavily impacted by poverty and HIV/AIDS. Specifically, we draw on screening data from caregivers of 2434 children that used well-established standardized measures that had been pre-tested in the region. These were: 1) oppositional defiant disorder (ODD) and conduct disorder (CD) subscales of the Disruptive Behavior Disorders (DBD) scale; and 2) the Iowa Connors and Impairment scales. Slightly over half of the children in the sample were female (52%), with a mean age of 10.27 years.

RESULTS

Of the 2434 participants screened for disruptive behaviors: 1) 6% (n = 136) scored positive on ODD and 2% (n = 42) scored positive on CD subscales of the DBD scale; 2) 9.61% (n = 234), and 2.67% (n = 65) were reported to have elevated symptoms of ODD and ADHD on the Iowa Connors caregiver report scale respectively. Twenty-five percent (n = 586) of children were described by their caregivers as having experienced some form of impairment in at least four domains of the Impairment scale.

CONCLUSION

The results indicate the presence of behavioral challenges and ADHD among school going children, aged 8-13 years, in Uganda. Given the negative outcomes associated with behavioral challenges as children transition to adolescence and adulthood, detecting these emerging behavioral challenges early is critical in developing appropriate interventions. School settings could be considered as one of the contextually-relevant, culturally-appropriate, and non-stigmatizing venues to implement screening procedures and to detect emerging behavioral challenges and to make necessary referrals.

Lost in transition: A review of the unmet need of patients with attention deficit/hyperactivity disorder transitioning to adulthood

This review discusses the unmet needs of patients with attention deficit/hyperactivity disorder (ADHD) who are transitioning into adulthood. Although awareness and recognition of ADHD in children, adolescents, and adults have improved in recent years, there is often an interruption in management of the disorder when adolescent patients transition to adult health care services. This review has the following objectives: (1) to identify key issues patients with ADHD (with or without an early diagnosis) face during transition into adulthood; (2) to review the current clinical practice and country-specific approaches to the management of the transition into adulthood for patients with ADHD; (3) to discuss challenges facing clinicians and their patients when drug treatment for ADHD is initiated; (4) to review current ADHD guidelines on transition management in Hong Kong, Singapore, South Korea, Turkey, and Africa; and (5) to examine economic consequences associated with ADHD. The review suggests that the transition period to adult ADHD may be an underresearched and underserved area. The transition period plays an important role regarding how ADHD symptoms may be perceived and acted upon by adult psychiatrists. Further studies are needed to explore the characteristics of the transition period. If only a fraction of adolescents go on to have mental disorders during adulthood, especially ADHD, it is crucial to identify their characteristics to target appropriate interventions at the beginning of the course of illness. There continues to be low recognition of adult ADHD and a severe lack of medical services equipped to diagnose and care for patients with ADHD transitioning from child to adult services.

Prevalence and associated factors of attention deficit hyperactivity disorder (ADHD) among Ugandan children; a cross-sectional study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neuropsychiatric disorder among the children. The burden of ADHD or its associated factors in Uganda are not known. The objective of this study was to determine the prevalence and the associated factors of ADHD among children attending the neurology and psychiatry clinics at Mulago National Referral Hospital.

METHODS

Using the disruptive behavior scale (45 items), we investigated the presence of ADHD symptoms among children attending Mulago Hospital. Questionnaires were administered to the primary care-takers of the study participants to gather information on the factors associated with ADHD. All children were subject to a clinical examination. Children presumed to have ADHD, using the aforementioned rating scale were further assessed by a child psychiatrist to confirm the diagnosis and associated co-morbid conditions.

RESULTS

The estimated prevalence of DSM-IV ADHD symptoms was 11%. Children aged less than 10 years were four times likely to have ADHD (OR 4.1, 95% CI 1.7-9.6, p < 0.001). The demographic factors independently associated with ADHD were age less than 10 years, male gender, history of maternal abnormal vaginal discharge during pregnancy, and no formal education or the highest level of education being primary school.

CONCLUSION

The prevalence of ADHD among children attending the pediatric neurology and psychiatry clinics is high in our settings and is associated with delayed milestones. Early identification and addressing the co-morbid conditions associated with ADHD such as epilepsy, autism spectrum of disorder, conduct disorder, opposition defiant disorder and intellectual disability in our setting is needed.

EEG Brain Wave Activity at Rest and during Evoked Attention in Children with Attention-Deficit/Hyperactivity Disorder and Effects of Methylphenidate

OBJECTIVE

The aim of this study was to assess baseline EEG brain wave activity in children with attention-deficit/hyperactivity disorder (ADHD) and to examine the effects of evoked attention and methylphenidate on this activity.

METHOD

Children with ADHD (n = 19) were tested while they were stimulant free and during a period in which they were on stimulant (methylphenidate) medication. Control subjects (n = 18) were tested once. EEG brain wave activity was tested both at baseline and during focussed attention. Attention was evoked and EEG brain wave activity was determined by means of the BioGraph Infiniti biofeedback apparatus.

RESULTS

The main finding of this study was that control subjects and stimulant-free children with ADHD exhibited the expected reactivity in high alpha-wave activity (11-12 Hz) from baseline to focussed attention; however, methylphenidate appeared to abolish this reactivity.

CONCLUSION

Methylphenidate attenuates the normal cortical response to a cognitive challenge.

Executive function and attention-deficit/hyperactivity disorder in Ugandan children with perinatal HIV exposure

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is among the most commonly diagnosed mental disorders in childhood and is associated with substantial deficits in executive functioning and lost academic and occupational attainment. This study evaluates symptoms of ADHD and their association with neurocognitive deficits in a cohort of rural Ugandan children who were born to HIV-infected mothers.

METHODS

We assessed ADHD symptoms and executive function (including memory and attention) in a non-clinical sample of children born to HIV-infected mothers in rural eastern Uganda. Analyses included assessments of the psychometric properties, factor structure, and convergent and discriminant validity of the ADHD measure (ADHD-Rating Scale-IV); and executive function deficits in children meeting symptom criteria for ADHD.

RESULTS

232 children [54% female; mean age 7.8 years (s.d. 2.0)] were assessed for ADHD and executive function deficits. The ADHD measure showed good internal consistency (α = 0.85.) Confirmatory factor analysis showed an acceptable fit for the diagnostic and statistical manual of mental disorders (DSM-5) two-factor model. Subjects meeting DSM-5 symptom criteria for ADHD had worse parent-rated executive function on six out of seven subscales.

CONCLUSIONS

Our results demonstrate structural validity of the ADHD measure with this population, strong associations between ADHD symptom severity and poorer executive function, and higher levels of executive function problems in perinatally HIV-exposed Ugandan children with ADHD. These findings suggest that ADHD may be an important neurocognitive disorder associated with executive function problems among children in sub-Saharan African settings where perinatal HIV exposure is common.