Indian Pediatrics 1999;36:583-587 

Attention Deficit Hyperactivity Disorder Among Psychiatric Outpatients

M.S. Bhatia
S. Choudhary
Ajeet Sidana

From the Department of Psychiatry, UCMS and GTB Hospital, Dilshad Garden, Delhi I/O 095, India.

Reprint requests: Dr. M.S. Bhatia, D-I, Naraina Vihar, New Delhi-I10 028, India.

Manuscript Received: July 21, 1998; Initial review completed: September 7, 1998;
Revision Accepted: December 7, 1998.

In Child Guidance Clinics, a significant number of children are brought with the complaints of difficulties in school and at home that relate to their learning and behavior. The clinical findings of distractability, impulsivity and hyperactivity characterize attention deficit hyperkinetic disorder (ADHD)(l,2).

Probably the first reliable description of ADHO or in short also called ADD (Attention Deficit Disorder), comes from England in early 20th century. The prevalence of the disorder varies from 1 % to 20%, depending on the diagnostic criteria employed, the population of children studied, the methods of investigation and the sources of information(3). Around 60% of ADHD children will carry some of their behavior into adulthood(3). In the last decade, Western Literature on this syndrome has grown(3-6) but in India only a few studies(7,8) have been done. The present study was conducted in order to determine: (a) the prevalence of ADHD among children (aged 3-12 years) attending psychiatry out-patient department; (b) the relationship of various socio-demographic variables to ADHD and (c) the psychiatric comorbidity of ADHD.

Subject and Methods

The present study was conducted in a Psychiatry Outpatient Department of a tertiary care teaching hospital. All the cases attending the outpatient department were recorded as per DSM-IV diagnostic criteria(1). The child's detailed obstetric and perinatal history, developmental milestones, early temperamental disposition, the child's as well as family's medical, psychiatric and psycho- logical history were recorded on a semi- structured format. All the children were subjected to a detailed general physical and systemic examination and relevant investigations were done, whenever required. Children with (a) acute physical illness, (b) chronic physical disability (such as deafness or visual defect), (c) gross brain damage, (d) epilepsy, (e) autism, (j) psychosis, (g) unreliable history were excluded from the study. The child and at least one of the parents were inter- viewed. The children were then subjected to detailed mental status examination andpsychological evaluation. Socio-economic status was assessed on Kuppuswamy scaIe(9).

Results

Of 362 children (aged 3-12 years) attending the Outpatient Clinic, 64 (17.7%) were found to have ADHD. The sex distribution of all the children attending clinic was 58% boys and 42% girls (1.4 : I) whereas the boy: girl ratio of 3:1 among children with ADHD was significantly different from that in the sex distribution of children in the outpatient clinic (Table I).

The mean age of boys with ADHD was 9.1 years (SD :t 1.15) whereas the mean age of the girls 7.9 years (SD :t 1.35). This sex difference was statistically significant (p(Table I) and was significantly more common among the lower social classes in both sexes (p(Table II). Outof64 cases with ADHD, 28 (43.8%) were first born in the sibship.

The associated biological and psycho- social factors showed that antenatal complications, incidence of slow development, broken homes, aggressive behavior by parents and psychiatric illness among parents were more common in children with ADHD. There was however, no statistically significant difference when the history of hyperkinesis in parents or sibs was compared with other children. There was no association of ADHD with parental education or maternal age at the time of delivery. Temper-tantrums, enuresis and tics were found to be significantly more common in the ADHD group.

Discussion

The prevalence of ADHD among children attending pediatric outpatients was found to be 17.7%. It has been reported by various Western (10,1 I) and Indian workers (12, I 3) that the prevalence of ADHD in children is between I % and 20%. One of the reasons for the difference in the prevalence of ADHD in these studies is the variation in data source.


                                                          TABLE I

                          Distribution of Cases According to Age and Sex

Age (yr)	Boys Total cases	Boys ADHD (%)	Girls Total cases		Girls ADHD (%)	Distribution combined Total cases		Distribution Combined ADHD (%)
3- 4	52	9[17.3]	44		3 [6.8]	96			12 [12.5]
5- 6	63	12[19.0]	35		3 [8.6]	98			15 [15.3]
7- 8	41	8 [19.5]		51	4 [7.8]	92			12 [13.0]
9-10	32	II [34.4]		9	2 [22.2]	41			13 [31.7]
1I-12	22	8[36.4]		13	4 [30.7]	35			12 [34.3]
Total	210	48[22.9]		152	16 [10.5]	362			64 [17.7]
		TABLE II Relationship of ADHD With Social Class
Social	Boys	Boys	Girls		Girls	Combined			Combined
class	total cases	ADHD(%)	total cases		ADHD (%)	total cases			ADHD(%)
I and II	82	11 [13.4]	58		4 [6.9]		140		15[10.7]
III,IVandV    128		37[28.9]	94		12[12.8]		222		49 [22.1]
Total	210	48[22.9]	152		16[10.5]		362		64 [17.7]

The male female ratio of 3: 1 is statistically significant. Epidemiological surveys in Western countries (10,14,15) have reported a greater incidence in boys than in girls, the ratio ranging from 2: 1 to 10: 1 whereas Indian studies have reported ADHD to be 3.3 to 7.7 times more common among boys than girls (8,13, 16). The gender differences strengthen the evidence for a biologically based, often genetically transmitted, etiology of hyper- kinetic disorder(17,18). ADHD was found to be significantly more prevalent in boys and girls between the age groups 11-12 years (34.3%) and 9-10 years (31.7%). This finding is in accordance with that reported by other studies (11,12,13).

In the present study, ADHD was associated with the first born status. Rutter et al., have reported that 20-30% of cases suffering from ADHD are first born children. Some Indian studies(13) have also found 24-54% of ADHD cases to be the eldest but a twin study by Godman and Stevenson(17) could not find any relationship between birth order and hyperactivity. A first delivery and a complicated delivery is more likely to produce brain damage in the infant during delivery (3,4,10,13,19). The signs of such damage may become main fest as ADHD(3, 1 0). However, certain workers (17,22) have not found a significantly higher rate of perinatal risk factors.

As reported by other workers (3,7,12,15) ADHD was significantly more common in children belonging to a lower social class. This could be explained by the fact that the children belonging to a lower social class are at an increased risk of having various psychiatric problems, because factors such as complicated pregnancy and parturition, mal- nutrition and exposure to environmental toxins and a greater likehood of CNS damage are commonly associated with poor socio- economic status. The unhappy family atmosphere, including the parent's marital conflicts and negative or inconsistent parenting increase the risk of hyperactivity accompanied by conduct disorder(20-22). This is also reflected by a significantly higher incidence of psychiatric illness among parents (alcoholism, depression and psychopathy in fathers; hysteria in mothers) in the present study and also been reported by others(1,3,7).

The incidence of slow development was significantly higher in children with ADHD. This is in accordance with other reports (3,7) and could be due to CNS damage because of prenatal, perinatal and postnatal complications (3,4,7) as was found in the present study. The incidence of broken homes, persistant parental discord or complaints of aggressive behavior by parents was also more common in the ADHD group. This has also been reported by. other studies(7,23). The higher incidence of such factors in ADHD could be seen as an indication that disrupted and disorganized homes are less likely to provide the stimuli that promote maturation of attention span or the parents may displace onto a child chosen for the role of a scapegoat the tensions between them. Alternatively the child with ADHD could cause disruption in the family which is supported by the finding that drug induced remissions in hyperactivity can result in substantial improvement in family relationships(23 ,24) .

Many family, twin and adoption studies have indicated an important role for heredity (1,17) but in the present study the incidence of hyperkinesis was not found to be significantly higher among parents of children with ADHD.

Among the associated disorders, temper- tantrums, tics and enuresis were found to be significantly more common in children with ADHD. This could be an expression of underlying emotional problems due to frustration and failure these children experience( 4,10). One of the recent studies(25) has reported ADHD in 50% of drug abusers in the adolescent group. These subjects began drug use at an earlier age, had more severe sub- stance abuse, and had a more negative self image prior to drug use and improved self- image with drug use. Similarly, another study(26) has reported a significant association between ADHD and cigarette smoking.

There are many important clinical implications of the results. The prevalence of ADHD was found to increase with age. The higher incidence of delayed development, broken homes and parental discord in children with ADHD calls for appropriate intervention in the family both for treatment and prevention. The significantly higher incidence of temper-tantrums, tics and enuresis in children with ADHD may require multiple diagnoses rather than ADHD alone. The therapist, by becoming aware about the multiple diagnoses in child with ADHD shall apply more specific interventions for such children.

 References