Manar Al Azzam 1, Mohammed Al Bashtawy 1, Ahmad Tubaishat 2, Abdul-Monim Batiha 3 and Loai Tawalbeh 2
انتشار اضطراب قصور الانتباه المقترن بفرط النشاط بين الأطفال في سن المدرسة في الأردن
منار العزام، محمد البشتاوي، أحمد طبيشات، عبد المنعم بطيحة، لؤي طوالبة
الخلاصة: الغرض من هذه الدراسة هو تحديد مدى انتشار اضطراب قصور الانتباه المقترن بفرط النشاط بين أطفال المدارس في الأردن، وعوامل الخطر المحتملة المرتبطة به. واستُخدمت دراسة وصفية مقطعية وعينه عشوائية بسيطة لاختيار 480 طالباً، تتراوح أعمارهم بين 6 سنوات و12 سنة، من المدارس الابتدائية الحكومية في مدينة المفرق بالأردن. وجُمعت بيانات الدراسة باستخدام النسخة العربية المعدّلة من الإصدار المدرسي لمقياس تقييم اضطراب قصور الانتباه واستبيان أولياء الأمر. وأظهرت النتائج أن معدلات الانتشار في النوع الفرعي «تشتُّت الانتباه» والنوع الفرعي «فرط الحركة/الاندفاع»، والنوع الفرعي المجمّع بلغت 10.83 %، 9.58 %، 20.21 % على التوالي. وترتبط زيادة حجم الأسرة والذكورة بزيادة انتشار أعراض هذا الاضطراب. وكشفت الدراسة انتشار اضطراب قصور الانتباه المقترن بفرط النشاط في صفوف طلاب المدارس الأردنية. وينبغي للحكومة وضع برامج تعليمية لزيادة الوعي بجوانب اضطراب قصور الانتباه المقترن بفرط النشاط.
ABSTRACT The purpose of this study was to determine the prevalence of attention deficit hyperactivity disorder (ADHD) symptoms among school children in Jordan and the probable associated risk factors. This was a cross-sectional descriptive study and simple random sampling was used to select 480 students, aged 6–12 years, from government primary schools in Mafraq City, Jordan. Data were collected using the modified Arabic version of the Attention Deficit Disorder Evaluation Scale (ADDES) school version and parental questionnaire. Prevalence rates within the inattentive, hyperactive–impulsive and combined subtypes were 10.83, 9.58 and 20.21%, respectively. Increased family size and being male were both associated with increased prevalence of ADHD symptoms. The study revealed that ADHD is common among Jordanian school children. The government should establish education programmes to increase awareness of ADHD.
Prévalence du trouble de déficit de l’attention avec hyperactivité (TDAH) parmi des enfants d’âge scolaire en Jordanie
RÉSUMÉ La présente étude a pour objectif de déterminer la prévalence des symptômes du trouble de déficit de l’attention avec hyperactivité (TDAH) parmi des enfants scolarisés en Jordanie, ainsi que les probables facteurs de risque associés. Une étude descriptive transversale ainsi qu’un sondage aléatoire simple ont été utilisés afin de sélectionner 480 élèves, âgés de 6 à 12 ans, dans des écoles primaires gouvernementales de la ville de Mafraq, en Jordanie. Les données de l’étude ont été collectées en utilisant la version scolaire modifiée de l'échelle d'évaluation du trouble de déficit de l’attention (ADDES) en langue arabe et un questionnaire destiné aux parents. Les résultats ont montré que les taux de prévalence du sous-type inattentif, du sous-type hyperactif/impulsif, et du sous-type combiné étaient de 10,83 %, 9,58 %, et 20,21 % respectivement. Le fait d'être une famille nombreuse et d’être de sexe masculin était associé à une prévalence accrue des symptômes de TDAH. L’étude a révélé que le TDAH était répandu parmi les élèves scolarisés en Jordanie. Le gouvernement devrait mettre en place des programmes éducatifs afin de sensibiliser sur les aspects du TDAH.
1Department of Community and Mental Health Nursing, Faculty of Nursing, Al al-Bayt University, Al-Mafraq, Jordan (Correspondence to: M. Al Azzam: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). 2Department of Adult Health Nursing, Al al-Bayt University, Al-Mafraq, Jordan. 3Department of Adult Health Nursing, Faculty of Nursing, Philadelphia University, Amman, Jordan.
Received: 01/05/16; accepted: 23/11/16
Introduction
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by core symptoms of hyperactivity, inattention and impulsivity, affecting children across all socioeconomic strata and ethnic and regional groups (1,2). Forty to sixty percent of children with ADHD have comorbidity such as anxiety, depression and learning disabilities (1). Fifty percent of ADHD cases are associated with disruptive and aggressive behavioural characteristics as seen in oppositional defiant disorder and conduct disorder (3). ADHD may serve as a developmental precursor to increasingly problematic behavioural outcomes, because children with ADHD are at significantly higher risk of being involved with substance abuse, delinquency and persistent problems with social relationships, as well as academic and job performance difficulties (1,4–6).
The emotional and behavioural problems associated with ADHD may interfere with nearly every aspect of a child’s life, including family and sibling relationships, peer relationships, academic performance, planning, and task completion (1,3,7). ADHD has a significant lifelong impact on a person’s emotional, social and cognitive functioning.
Factors that contribute to the aetiology of ADHD are still under investigation (1,8). Various approaches have been used to try to explain the aetiology, including biological, neuro-psychobiological, trauma-based, and environmentally based models, or a combination of these. It is reported that several child, family and environmental risk factors might increase the severity of ADHD symptoms (3). These factors include low socioeconomic status, living in economically stressed neighbourhoods, poor family functioning, family size, age, and gender. ADHD is a complex disorder, with genetic and environmental risk factors contributing to its onset (1,9).
ADHD is one of the most common neurodevelopmental disorders of childhood, with a worldwide prevalence ranging from 2.2 to 17.8% (10). The variability in prevalence might be due to several factors, such as study methodology, diagnostic criteria, populations studied, sample size, cultural perceptions, and informants (e.g., respondents to questionnaires) (1,6,9,10). Moreover, the literature indicates that the reported rates might vary depending on the source of the information (1,3,11).
In Arab countries there has been a shortage of studies addressing children’s behavioural problems in general and ADHD in particular (8). The prevalence of ADHD symptoms in Arab countries varies considerably between 1.3 and 16% (8,12–14), although these rates were based on a limited number of studies that used different methods. For example, Richa and colleagues (14) conducted a study of 1000 Lebanese school children aged 6–10 years using the ADHD Rating Scale – IV School Version. They found prevalence of 3% for ADHD inattentive subtype, 12% for hyperactive–impulsive subtype and 17% for ADHD combined subtype. Jenahi and colleagues (13) used the Attention Deficit Disorders Evaluation Scale (ADDES) to investigate the prevalence of ADHD among 1009 Saudi students aged 6–15 years. They found prevalence of 2.1% for ADHD inattentive subtype and 5.6% for hyperactive–impulsive subtype.
The main purpose of the current study was to determine the prevalence of ADHD symptoms among school children in Jordan. We also aimed to identify possible risk factors related to the symptoms associated with ADHD. It is hoped that the current study will provide baseline information that may help teachers, parents, healthcare professionals and policy-makers to design comprehensive strategies to enhance awareness of ADHD. Also, the study may be a preliminary step toward launching a large community-based study that might help to develop awareness and intervention programmes to deal with affected individuals and their families.
Methods
Research design
This was a cross-sectional descriptive study to assess the prevalence of ADHD among school children in Jordan, together with the associated risk factors. The study was conducted at schools in Mafraq City, Jordan from February to April 2014. Mafraq is located 80 km north of the capital Amman. It has nearly 127 830 residents. There are 30 governmental schools listed in the city, with a total of 19 000 students (15). The study was approved by the Institutional Review Board of Al al-Bayt University, Mafraq.
Study population
The target population was school children aged 6–12 years. A list of the primary schools in Mafraq City was obtained from the Ministry of Education. A random sample of 6 schools was chosen. Six classes, 1 from each grade in each school, were chosen using systematic random sampling to ensure representativeness of all classes of the same grade. Proportional allocation of the sample was used when choosing the children so that the sampling fractions were equal.
The sample size was determined using the following formula:
N = Z2 1 –α/2 × P (1 – P) / d2
where N is minimum sample size; Z2 1 − α/2 is the confidence level at 95%; P is the expected prevalence of ADHD symptoms among school-aged children (0.5%); and d is the margin of error at 0.05% (4). The minimum sample size needed was 400 students, but, to allow for non-responses and uncompleted questionnaires, we increased the sample size to 500 students.
Exclusion criteria
All students in the selected classes were eligible to participate in the study, except for children who were not Jordanian. This was because non-Jordanian children may have been refugees with other diagnoses that could have interfered with ADHD symptoms. We also excluded children with chronic physical illness and those attending special educational classes to compensate for learning disabilities, because the diagnosis of ADHD is often comorbid with other diagnoses such as learning disabilities.
Study instruments
Two instruments were used to assess the main variables. The modified Arabic School Version of ADDES was used to measure the prevalence of ADHD symptoms (Appendix 1). Permission to use the instrument was obtained from Hawthorne Educational Service (Colombia, MO, USA). The questionnaire contained two parts: Part I consisted of 29 questions that measured inattention; and Part II comprised 31 questions that measured hyperactivity–impulsivity. All 60 questions were used to diagnose combined ADHD. The same scoring procedure, as outlined in the original manual, was used by the authors.
The Arabic version of the instrument was established by translation and back translation and the content validity was checked by a panel of experts who were interested in the research topic. The instrument was piloted with 30 students who were not included within the main sample, before the data collection process began, to assess the clarity and appropriateness of items and to test the readability of the instrument among a Jordanian sample. The results indicated that the instruments were clear and readable. The findings also showed that Cronbach’s α was 0.93.
An Arabic questionnaire was devised to collect relevant sociodemographic data for the present study, including children’s age, birth order, number of siblings, parents’ educational level, family mental health history, and consanguinity.
Data collection and procedures
After obtaining IRB approval, 2 research team members visited the schools and explained the aims and methods of the study to the head teacher, in order to obtain permission to distribute the study forms. A letter of invitation to participate in the study was sent to the children’s parents and the head teachers. The letter explained the aims and methods of the study, name and contact information of the chief researcher, and that participation was voluntary. All participants’ rights about anonymity and confidentiality were protected. The head teachers were instructed to fill out the modified Arabic school version of ADDES after they had received appropriate training. Parents were instructed to fill out the demographic data questionnaire.
Data analysis
The completeness and accuracy of the study data were checked and then coded, entered and analysed using SPSS version 22. Descriptive statistics were used to describe the sample characteristics and to assess the prevalence of ADHD symptoms. The χ2 test was used to assess whether there was a significant association between ADHD symptoms and demographic data. P < 0.05 was considered statistically significant. Binary logistic regression was performed to identify the factors that may have contributed to the prevalence rate of ADHD. To assess the predictors of the prevalence rate of ADHD, the following predictors were entered into the regression equation: age, gender, birth order, number of siblings, maternal educational level, paternal educational level, consanguinity, and family mental health problems.