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Study of the prevalence of the attention deficit hyperactivity disorder in ten-year-old children living in the Valencia metropolitan area
Abstract
The point prevalence of Attentional Deficit Disorder with Hyperactivity is estimated in a random sample of 387 10-year-old children selected from the municipal census of the city of Valencia (Spain). A number of associated factors are described, along with the utilization of public health services. Diagnosis was established according to DSM-III-R criteria. The instruments used were: K-SADS-E; GAF Scale; Raven Progressive Matrices Test and Sociodemographic, Health and Services Use Information Questionnaire. Prevalence was estimated at 8.01 +/- 2.7% (mild 3.9%; moderate 3.9%; severe 0.3%). The male/female ratio was 2:1. Attentional Deficit Disorder with Hyperactivity was significantly associated with low academic performance and the condition of living with only one parent. These children made use of the psychological support services with significantly greater frequency than non hyperactive children, regardless of the degree of severity or academic performance.
... The fourteen studies provided the exact number of ADHD cases in the study population and the relevant prevalence rates, with values ranging from 1% to 14% [2,5,14]. Ten studies reported the male-to-female ratio [3,13-17,19-24] and the prevalence of ADHD was generally higher in men than in women, with a 4:1 ratio in four studies [14,17,22,24] and 2:1 in three studies [3,13,20]. ...
... Epidemiological studies in several countries have used questionnaires and scales based on symptoms as a criterion for ADHD. According to previous studies, in Spain the prevalence of ADHD would be 3-14% in children aged 8-15 years in Valencia [2,3], 4-6% in children aged 6-15 years in Seville [4] and 1% in children aged 6-8 years in Navarre [5]. Therefore, it would be relevant that the data provided in the scientific literature were analysed through integrated approaches which allow for establishing the extent of ADHD and its epidemiological characteristics for the whole children and adolescent population. ...
... The fourteen studies provided the exact number of ADHD cases in the study population and the relevant prevalence rates, with values ranging from 1% to 14% [2,5,14]. Ten studies reported the male-to-female ratio [3,13-17,19-24] and the prevalence of ADHD was generally higher in men than in women, with a 4:1 ratio in four studies [14,17,22,24] and 2:1 in three studies [3,13,20]. ...
Background
Attention deficit hyperactivity disorder (ADHD) is a commonly diagnosed neuropsychiatric disorder in childhood, but the frequency of the condition is not well established in many countries. The aim of the present study was to quantify the overall prevalence of ADHD among children and adolescents in Spain by means of a systematic review and meta-analysis.
Methods
PubMed/MEDLINE, IME, IBECS and TESEO were comprehensively searched. Original reports were selected if they provided data on prevalence estimates of ADHD among people under 18 years old in Spain and were cross-sectional, observational epidemiological studies. Information from included studies was systematically extracted and evaluated. Overall pooled-prevalence estimates of ADHD were calculated using random-effects models. Sources of heterogeneity were explored by means sub-groups analyses and univariate meta-regressions.
Results
Fourteen epidemiological studies (13,026 subjects) were selected. The overall pooled-prevalence of ADHD was estimated at 6.8% [95% confidence interval (CI) 4.9 – 8.8%] representing 361,580 (95% CI 260,550 – 467,927) children and adolescents in the community. There was significant heterogeneity (P < 0.001), which was incompletely explained by subgroup analyses and meta-regressions.
Conclusions
Our findings suggest that the prevalence of ADHD among children and adolescents in Spain is consistent with previous studies conducted in other countries and regions. This study represents a first step in estimating the national burden of ADHD that will be essential to building evidence-based programs and services.
... En Europa, la prevalencia se sitúa entre el 1,2-6% de los escolares de 6-7 años. En España, existen pocos estudios pero las cifras parecen similares con una prevalencia entre el 3-5% de los escolares si bien algún estudio, como el realizado en la comunidad valenciana, recoge cifras de hasta el 8,1 + 2,7% a la edad de 10 años 3 . El trastorno es más frecuente en los niños siendo la relación niño/niña de 2/1 -4/1, aunque esto parece traducir un infradiagnóstico de casos en niñas, en quienes predomina el trastorno de tipo inatento, de más difícil diagnóstico. ...
Attention deficit disorder has a high prevalence in the infant population: from 3 to 5% of children of school age and, it could be as high as 8.1 + 2.7% of children at ten years of age, according to a study in the autonomous community of Valencia. It is a persistent problem whose manifestations can change in the course of its development, from pre-school age to adult life. In this paper we review the disorder in its epidemiological and etiological aspects, its natural history and its prognosis, as well as its diagnosis and treatment. We set out our experience with children and their families in two primary care paediatric units of the Navarra health service in two different settings - rural and urban. Finally, we draw attention to some of the difficulties faced in dealing with this disorder in a reasonable way.
... Genetic factors play an important role in its pathogenesis [16, 22], and the disorder appears to be associated with dysregulation of cortical dopaminergic and noradrenergic function [5, 32]. Epidemiologic studies in the United States suggest that the prevalence of ADHD in school-aged children is approximately 3 to 7 % [3] , a figure consistent with studies in a number of other countries [4, 12, 17, 18, 32, 36, 38] . Outside North America, the disorder is more controversial , and tends to be less commonly treated with pharmacologic interventions [6, 11, 26, 34]. ...
The aim of this study was to study treatment response to atomoxetine in a large, multicenter study of non-North American patients with ADHD.
A total of 604 children and adolescents with ADHD were enrolled in a 10-week open-label trial with atomoxetine prior to randomization to a double-blind relapse prevention phase at 33 sites in the United Kingdom, continental Europe, Israel, South Africa, and Australia. All patients had ADHD symptom severity at least 1.5 standard deviations above United States age and gender norms for their diagnostic subtype as measured by the investigator-scored ADHD Rating Scale (ADHD RS). Outcomes were assessed by analysis of change in the ADHD RS; functional and psychosocial outcomes were assessed using the Child Health Questionnaire (CHQ).
At endpoint, ADHD RS total scores decreased by an average of 56.7%, and 69% of patients were rated as having no or minimal symptoms. Significant improvement was observed in psychosocial and functional outcomes. Discontinuations attributed to adverse events were < 4%.
These open-label data, gathered in an international setting, add to our knowledge of the value of atomoxetine in treating ADHD symptoms, as well as its safety and tolerability.
The action of Ginkgo biloba (Ginkgarom®) was investigated in 50 hyperactive children (attention deficit hyperactivity disorder, ADHD) aged from 2 to 13 years. The diagnosis of ADHD was based on the DSM-IV Criteria of the American Psychiatric Association as well as on a basal value of the Conners Global Index CGI of 14 or more. The CGI was also used as the evaluation instrument and was assessed by the parents of the patients before and at the end of a 4-week treatment period. The evaluation data from 25 ADHD-children treated with Ritalin® were used for comparison of its efficacy with that of methylphenidate (MPH). Results: 28 of the 50 children (56%) responded well to Ginkgo biloba and achieved a mean improvement of 47% in the CGI rating, whereas 18 children (36%) reacted inadequately with a mean 6% improvement of the CGI. In 4 children (8%) there was a deterioration of 15% on average of the CGI. On comparison of the profile of action of Ginkgo biloba and methylphenidate, it was found that Ginkgo biloba had a greater effect on excitability, frustration tolerance and mood than MPH, whereas the latter primarily improved concentration and restlessness. Difficulty in getting to sleep in one patient was the only adverse effect observed in the Ginkgo biloba group. The herbal taste of the drug led to compliance problems in a few children.
El trastorno por deficit de atencion e hiperactividad (TDAH) es un cuadro clinico frecuente en la infancia que afecta entre el 6 y el 10% de los ninos en edad escolar 1 . Se asocia con retraso y dificultades del funcionamiento academico y social 2 , y hay evidencia creciente que indica que tambien se asocia con morbilidad significativa y peor funcionamiento en la edad adulta 3,4 . Ademas, estudios longitudinales recientes senalan que los ninos con TDAH de ambos sexos y de cualquier edad generan un gasto medico total y una utilizacion de recursos medicos (hospitalizacion, visitas en consulta y urgencias) de mas del doble que los ninos de igual edad sin TDAH (p < 0,001), lo que significa que la «carga» negativa del TDAH se extiende mas alla de los parametros sociales, conductuales y academicos 5 . El TDAH es el trastorno psiquiatrico mas frecuente en la infancia 6 , y es un trastorno heterogeneo, de comienzo en la infancia, con un impacto enorme en la sociedad en terminos de coste economico, estres familiar, adversidad academica y vocacional, y con un claro efecto negativo sobre la autoestima del sujeto afectado 7 . Esta entidad clinica se denomina TDAH segun criterios del DSM-IV y trastorno hipercinetico (una forma mas grave y menos frecuente)
Introduction:
The CONCOR study aimed to determine the predictive value of the SNAP-IV screening tool for ADHD relative to the pediatricians' clinical global impression of the presence of ADHD in children attending their practice.
Methods:
In this multicentre, cross-sectional, case-control study participated pediatricians from all over Spain and each pediatrician enrolled at least six children over the age of 6 years who had no previous diagnosis of ADHD, three whom they considered to have symptoms characteristic of ADHD (DSM-IV criteria) and three children who did not. Screening with the SNAP-IV tool was completed by parents in the waiting room prior to a consultation (for any reason) and results were compared with the pediatrician's clinical global impression.
Results:
Results for 7263 Spanish children (>6 years of age) showed 'good' concordance between the SNAP-IV screening tool and the pediatricians' clinical impression of ADHD (kappa concordance index 0.6471; 95% confidence intervals: 0.6296-0.6646), with acceptable sensitivity and specificity (82.3% and 82.4%, respectively). Based on an estimated ADHD prevalence of 3-10%, the negative predictive values of SNAP-IV were 97.7%-99.3% and positive predictive values were 12.6-34.2%.
Conclusions:
SNAP-IV is a useful screening tool that identifies children who are unlikely to have ADHD, and brings those in whom there is a high possibility of ADHD to the attention of the pediatrician for clinical evaluation.
To validate the attention deficit hyperactivity disorder assessment scale (EDAH) for a teenage population.
Out of an initial sample of 3400 participants, a final sample of 2382 boys and girls was selected. This reduction in the number of participants was mainly due to parents' failing to sign the informed consent document (948 cases) and to incomplete questionnaires (70 cases). Finally, we extracted a sub-sample of those who presented scores above the 75 centile on the total EDAH factor of the questionnaire. This sub-sample consisted of 637 pupils, 258 of whom were girls (40.5%) and the remaining 379 were boys (59.5%), with ages between 11 and 17 years old.
The original test has proved to be useful in screening for attention deficit hyperactivity disorder in childhood. The main result of the factorial analysis with Varimax rotation performed on a sample of teenagers was the appearance of a new factor ('social interaction disorders'); the three factors of the original test were maintained, although with slight differences in their composition. High internal consistency was also observed by means of Cronbach's alpha coefficient (0.85), which confirmed the reliability of the scale. The sociodemographic variables sex and number of failed subjects account for a significant part of the variance of the total EDAH score (28%); in 'attention deficit', gender, age and number of failed subjects are the variables that exert the greatest influence; in 'social interaction disorders', age and number of failed subjects are involved; in 'hyperactivity', age and gender are the variables with the most weight; and in 'behavioural disorders', none of these variables have any repercussion on the scores that are obtained.
The aim of this study was to determine the relationship between several adversity factors and Attention Deficit Hyperactivity Disorder (ADHD), to evaluate the existence of associated factors and to investigate parental rearing behaviors.
Eighty subjects between 7 and 8 years of age were studied. These patients belonged to a transversal study of 263 subjects that had completed the Revised Conners' Parent and Teacher Rating Scales. The authors evaluated the presence of seven probable adversity factors including: low socio-economic status, large family size, history of psychiatric disorders in first grade family members, drug abuse in parents, presence of psychological problems in the mother, perinatal pathology in the child and "difficult" temperament during early childhood. The associated factors studied were accident proneness, left motor preference, soft neurological signs, low vocabulary coefficient, poor academic achievement, low self-esteem, symptoms of anxiety and depression. EMBU-P questionnaires were used to assess parental rearing behavior.
Two adversity factors were present in a statistically significant proportion, large family size and "difficult" temperament in early childhood, as well as two associated factors, left-handedness and low self-esteem. No statistically significant association between parental rearing behavior and ADHD was observed.
It is necessary to keep in mind the different risk factors and associated factors of ADHD which could help to make an early diagnosis of the disorder which is very important because of its high prevalence and co-morbility.
The sharp increase of the prescription of methylphenidate (MPD) in hyperactive children in recent years is a matter of increasing uneasiness among professionals, parents and politicians. There is little awareness of treatment alternatives. The purpose of this prospective trial was to assess the efficacy of homeopathy in hyperactive patients and to compare it MPD. The study was performed in a paediatric practice with conventional and homeopathic backgrounds. Children aged 3-17 y, conforming to the DSM-IV criteria for attention deficit hyperactivity disorder (ADHD) with a Conners Global Index (CGI) of 14 or higher were eligible for the study. All of them received an individual homeopathic treatment. When clinical improvement reached 50%, the parents were asked to reevaluate the symptoms. Those who did not improve sufficiently on homeopathy were changed to MPD, and again evaluated after 3 months. One hundred and fifteen children (92 boys, 23 girls) with a mean age of 8.3 y at diagnosis were included in the study. Prior to treatment the mean CGI was 20.63 (14-30), the mean index of the homeopathy group 20.52 and of the MPD-group 20.94. After an average treatment time of 3.5 months 86 children (75%) had responded to homeopathy, reaching a clinical improvement rating of 73% and an amelioration of the CGI of 55%. Twenty-five children (22%) needed MPD; the average duration of homeopathic (pre-) treatment in this group was 22 months. Clinical improvement under MPD reached 65%, the lowering of the CGI 48%. Three children did not respond to homeopathy nor to MPD, and one left the study. In cases where treatment of a hyperactive child is not urgent, homeopathy is a valuable alternative to MPD. The reported results of homeopathic treatment appear to be similar to the effects of MPD. Only children who did not reach the high level of sensory integration for school had to be changed to MPD. In preschoolers, homeopathy appears a particularly useful treatment for ADHD.
Although attention-deficit/hyperactivity disorder (ADHD) impairs millions of people worldwide, both the prevalence and existence of the disorder are being reevaluated at the phenotypic level. To safeguard against overdiagnosis, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), demands that individuals with ADHD have pervasive impairment, that is, impairment in more than 1 setting. However, the appropriateness of the DSM-IV classification of ADHD is also undergoing reevaluation. Like the symptoms of a developmental disability, the symptoms of ADHD must be evaluated in the context of age-based norms; therefore, the current criteria for ADHD, which are not age referenced, may minimize the rate of persistence of ADHD into adulthood. In an effort to better understand the pathophysiology of ADHD, recent research has focused on identifying the etiology of ADHD. These studies have revealed that the disorder is highly heritable and may be associated with neurobiological deficits in the prefrontal cortex and related subcortical systems. Etiologic studies have also identified candidate genes and prenatal and perinatal risk factors for ADHD. As the causes and course of ADHD are better understood, a new generation of medications is being developed for the disorder. Although stimulants are often effective in reducing the symptoms of the disorder, as a class they have limitations such as a lack of 24-hour-a-day coverage, unwanted side effects, potential for abuse, and lessened effectiveness in the context of some comorbidities. Therefore, the treatment characteristics of newer, more selective treatments such as atomoxetine should continue to be explored in ADHD.
We report normative data for a Turkish translation of the Current Symptoms Scale (CSS), a screening measure of adult attention-deficit/hyperactivity disorder (ADHD). The CSS yields 3 scores reflecting diagnostic criteria for: (1) ADHD, predominantly hyperactive-impulsive type; (2) ADHD, predominantly inattentive type, and (3) ADHD, combined type. For comparison purposes, we also present normative data from a community sample in the United States. Central tendency, variability, and correlation patterns among Turkish subjects (n=181) were similar to patterns demonstrated by respondents in the United States (n=114). Mann-Whitney U tests revealed that the Turkish and US groups did not differ significantly on the subscales assessing inattentive and hyperactive-impulsive symptoms. Both versions demonstrated acceptable levels of internal consistency (Cronbach's alpha coefficients ranged from 0.65 to 0.78 for the Turkish version, and from 0.63 to 0.75 for the English version). The Turkish version of the CSS demonstrated excellent test- retest reliability. The test-retest coefficient for the CSS (total score) was 0.82. The inattentive type subscale also showed good test-retest reliability, with r=0.78. The test-retest coefficient for the hyperactive-impulsive type subscale was appreciably lower, with r=0.68; albeit, in the acceptable range. Investigators have determined that many adults, initially diagnosed with ADHD as children, continue to demonstrate clinically significant symptoms. Since adult ADHD is associated with a number of comorbid psychiatric conditions and treatment of the underlying attentional, executive, and impulse control difficulties is associated with a reduction in comorbid psychiatric symptoms, the routine screening for adult ADHD in psychiatric and mental health settings may be warranted.
Attention-deficit/hyperactivity disorder (ADHD) is typically treated over extended periods; however, few placebo-controlled, long-term studies of efficacy have been reported.
In a global multicenter study, children and adolescents who responded to an initial 12-week, open-label period of treatment with atomoxetine, a nonstimulant treatment for ADHD, were randomized to continued atomoxetine treatment or placebo for 9 months under double-blind conditions.
A total of 416 patients completed acute atomoxetine treatment and were randomized. At end point, atomoxetine was superior to placebo in preventing relapse defined as a return to 90% of baseline symptom severity (proportion relapsing: atomoxetine 65 of 292 [22.3%], placebo 47 of 124 [37.9%], p =.002). The proportion of patients with a 50% worsening in symptoms post-randomization was also lower on atomoxetine (atomoxetine 83 of 292 [28.4%], placebo 59 of 124 [47.6%], p <.001). Compared with patients in the placebo group, atomoxetine-treated patients had superior psychosocial functioning at end point. Discontinuations for adverse events were low in both groups, and tolerability was similar to that observed in acute treatment trials.
In patients who responded favorably to 12 weeks of initial treatment, atomoxetine was superior to placebo in maintaining response for the ensuing 9 months. This result supports the value of maintenance treatment with atomoxetine in patients with ADHD who respond to initial treatment.
Few large, prospective clinical studies in Europe have assessed the validity and applicability of research methods used to study ADHD in North America. To assess comparability of study populations, we examined baseline patient characteristics from a group of North American studies against those of a large European/African/Australian study. All studies used identical diagnostic assessments and inclusion criteria, with ADHD diagnosis and the presence of comorbid psychiatric conditions confirmed using the KSADS-PL. Raters were trained and assessed to ensure uniform diagnostic and symptom severity rating standards. Six hundred and four patients (mean age = 10.2 years) enrolled in the non-North American study, and 665 patients (mean age = 10.4 years) enrolled in the North American study. The proportion of girls was higher in the North American studies (29.2% vs. 10.4%, p < 0.001). In both groups, most patients had a positive family history of ADHD and previous stimulant treatment. Fewer had the inattentive subtype of ADHD, and mean severity was slightly higher in the non-North American study. Results demonstrate that, when a uniform set of rigorous, standardized diagnostic criteria are used by skilled clinicians, the patient populations identified are generally similar. This supports the practice of generalizing results from treatment studies across geographies.
This study analyzes whether obese children have a higher risk of attention deficit/hyperactivity "characteristics" (AD/HD) than do children with other nutritional states.
This study included 35,403 participants from 486 community schools. They completed the AD/HD scale of the Strengths and Difficulties Questionnaire (SDQ) and were weighed and measured. 2879 of the participants were obese and 78 were morbidly obese (BMI>40).
A discrete, nonsignificant, increment was found in the AD/HD characteristics of male participants with morbid obesity, as compared with the other nutritional states. Among morbidly obese females, the prevalence of AD/HD characteristics was slightly superior, although not significantly, to that found in participants with normal weight, overweight or obese (BMI<40).
Among nonclinical populations with a communitarian origin, previous findings reporting high rates of AD/HD in obese children are not replicated. This increment in the prevalence of AD/HD among hospitalized obese children could be the result of selection bias.
The efficacy of atomoxetine in maintaining symptom response following 1 year of treatment was assessed in children and adolescents (n = 163) with DSM-IV defined attention-deficit/hyperactivity disorder (ADHD).
Subjects had previously responded to atomoxetine acutely and had completed 1 year of double-blind atomoxetine treatment. They were then randomly assigned in double-blind fashion to continued atomoxetine or placebo substitution for 6 months.
Atomoxetine was superior to placebo in preventing relapse (Wilcoxon test, p = .008) and in maintaining symptom response (ADHD Rating Scale IV score, p < .001). Among subjects assigned to discontinuation, the magnitude of symptom return was generally to a level of severity less than that observed at study entry.
Following 1 year of treatment with atomoxetine, continued treatment over the ensuing 6 months was associated with superior outcomes compared with placebo substitution. However, there was considerable variability between individuals in the magnitude of symptom return after drug discontinuation, suggesting that some subjects treated with atomoxetine for a year with good results may consolidate gains made during drug treatment and could benefit from a medication-free trial to assess the need for ongoing drug treatment.
To examine the effects on growth of long-term pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD), we present findings from an ongoing 5-year study of the efficacy and safety of treatment with atomoxetine.
North American patients, 6-17 years old at study entry (N = 1,312) and with Diagnostic and Statistical Manual of Mental Disorders,4th edition (DSM-IV) ADHD, were studied under open-label atomoxetine treatment. Sixty-one were studied up to 5 years.
After 1 month's treatment, patients weighed less than expected from their starting percentiles relative to population norms, with a maximum shortfall at 15 months and a return to expected weight by 36 months. Patients were slightly shorter than expected after 12 months, reaching a maximum shortfall at 18 months and returning to expected height by 24 months. Patients in the top quartile for body mass index (BMI) or weight at baseline, and those in the third quartile for height, showed 5-year decreases from expected values. Those below median height at baseline showed increases relative to expected values.
These interim results indicate that continuous atomoxetine treatment for up to 5 years has little or no long-term effect on juvenile growth and final stature for most patients, although persistent decreases from expected may occur in some patients who are larger than average before treatment.
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