1Department of Pediatric Nursing, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran.
2Department of medical Surgical Nursing, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran.
3Department of Medical Education, School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran.
ABSTRACTBackground and aims: Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent disorder in children. Due to the importance of the disorder in children and its complications, this study aimed to assess the relation of the disorder with demographic factors in students of schools located in the Hamadan city, west of Iran. Methods: In this study, 1000 students were selected through randomized cluster sampling from Hamadan elementary schools in 2014. Data were gathered using Conners questionnaire. Conners questionnaire completed by teachers and parents. Results were analyzed using SPSS statistical software through Chi-square, Pierson correlation coefficient, and T-test. Results: The overall ADHD prevalence rate in this sample was determined to be 11.3%. For boys, this prevalence rate of ADHD was 19.4% and had significant difference with girls (P<0.01). The prevalence of ADHD in families with 1-3 children was 8.7% while it was 15.8% in families with 4 children and more. The difference was statistically significant (P=0.003). There was also higher prevalence among children of parents with lower level of education. Conclusion: ADHD is prevalent in community of Iran. Results indicated that diagnosis must be based on exact and persistent psychological symptoms. It is necessary that schools authorities in region 1 and 2 of Hamadan city take steps to find the cases and manage them.
Children are among most vulnerable human beings. Normal physical growth of the children as well as their cognitive, emotional, social and ethical development takes place provided that they have a safe environment filled with compassion. Any negative change to these factors can negatively affect the psychological and behavioral health of children. Family can play a remarkable role in this regard.1 Hyperactive children are too hectic and cannot stay calm. They are uneasy and have a compulsion to destroy things. They show intensive curiosity and destroy home appliances. They like dangerous activities and are never scared of the consequences. This may cause some people think they are courageous, but these are all because of their disorder.2,3
This disorder is demonstrated by hyperactivity, impulsivity and attention deficit (American Association of Psychology, 1994); symptoms which leave irrecoverable effects on the affected child in school, society, and home, and leads to problems in education, and communication with peers and parents.3 These children have difficulty with their education since they cannot concentrate. They are easily distracted and respond to very little stimulations. Communication with peers is an increasing problem. They mostly make a negative image of themselves in the eyes of others because of their unruly behavior and aggressiveness.4
Researchers have found that hyperactivity together with attention deficit would be an adequate predictor for negative consequences in the future of the child. The disorder interferes with normal growth in childhood. Without a complete treatment, the mental impairments would be greater in adulthood. Therefore, early diagnosis and treatment are the key components of the management of ADHD.
Regarding the importance of health in childhood which ensures the proper process of growth and development and since a complete understanding of the prevalence of the disease in Iran is needed to accomplish any preventive measure, it was decided to determine the prevalence of the disease in one of Iranian provinces as a sample of Iran's population. This study was aimed to assess ADHD in students with different demographic status in number 1 and 2 educational regions in Hamadan city.
This cross-sectional study was conducted in Hamadan, Iran in 2014. Study was approved by ethics committee of the Hamadan University of Medical Sciences. Informed consent was sought from parents/caregivers of potential subjects before enrolling them into the study.
A random sampling was used among all students from grade 1 to 5 in all elementary schools in number 1 and 2 educational regions in Hamadan city. From each region, 500 students (250 boys and 250 girls) were selected (1000 students in total).
Data were gathered using Conners questionnaire for teachers and parents.5 ADHD was considered based on the analysis of both teacher and parents' questionnaires. If the total mark from both questionnaires was less than 60, between 60 and 65, and above 65 results were considered as healthy, suspicious or patient respectively. In the latter case, parents were referred to health centers for more specific interventions. This Conners questionnaire evaluates five factors of conduct, psychosomatic-impulsivity, hyperactivity, anxiety, and learning problems and has four choices scored from zero (never) to three (very high). Previous study in Iranian context reported 90.3% sensitivity and 81.2% specificity for this questioner.6
Data were analyzed using SPSS statistical software through T-test, Chi-square and Pearson correlation coefficient. The threshold of statistical significance was set at P<0.05.
The overall ADHD prevalence rate in this sample was determined to be 11.3%. The relation between some demographic factors of the children and ADHD such as the family income and number of boys and girls in the family were assessed in this study. Results showed that the majority of samples (63%) had a family income between 150-250 USD per month. Majority of samples (56%) were in grade 1 to 3, and 53.4% were male (Table 1). Majority of fathers (55.3%) were government employees or simple workers and majority of mothers (81.9%) were housewives. In terms of the number of children in family, 91.8% had 0-2 boys, and 89% had 0-2 girls.
Table 1: Demographic characteristics of samples
Less than 200 USD
More than 200 USD
Also, majority of samples (64.1%) lived in personal houses; majority of mothers (30.7%) and fathers (31.4%) had a high school diploma or under diploma (Table 2).
Table 2: Distribution of samples based on parents' education level
Unfinished high school
High school diploma or associate degree
Bachelor or higher
In relation with hyperactivity and attention deficit in two educational zones, results indicated that there were 2.6% and 2.41% in zones 1 and 2 respectively with no significant difference (Table 3). This is probably because the environmental factors in the two zones have been similar. Prevalence of the disease has been higher in zone one. Among boys, 19.2% had hyperactivity (Table 4) and a significant difference was observed (P=0.01). There was no significant difference between the education grade and health level. Also 88.7% of samples had not hyperactivity (Table 5). Majority of samples (73.7%) had no family history of hyperactivity, but in 20.1% of samples there was a history of hyperactivity or attention deficit in their parents and 19.4% were in age 9 to 11 (Table 6).
Table 3: Distribution of samples based on gender and education zones
Table 4: Distribution of samples based on gender and educational grade
Table 5: Distribution of samples based on hyperactivity
Table 6: Distribution of samples based on family history of hyperactivity
Family history of hyperactivity
Brother and sister
Uncles and aunts
The aim of present study was to examine prevalence of ADHD relation of the disorder with demographic factors in students of schools located in the Hamadan city, west of Iran. According to finding, prevalence was high among students in our city. Factors such as, sex, number of children in family, parent level of education, and family income increased this rate.
ADHD is one of the most common psychiatric disorders in child and adolescent psychiatry that negatively affect children’s quality of life.7,8 ADHD is an illness that not received enough attention in Iran. Similar to our finding, results of previous Iranian studies from various regions and large cities showed that prevalence of ADHD is high. In one study in this regards in 2007, Hebrani, et al. examined the prevalence of ADHD in preschool-age children in Mashhad, North East of Iran. About 12% of participants in Hebrani, et al. study showed the sign and symptom of ADHD.9 In another study in this regards among Iranian school aged children’s, Alizadeh et al. reported prevalence of ADHD as 7.2% that is lower than finding of present study.10 This difference could be related to different in sample of two study, because in our study we surveyed children in Hamadan city and Alizadeh et al. examined prevalence of ADHD among children who live in rural area.10 Study among other country showed different finding.11,12 In one study in 2015, Aboul-Ata and Amin examined the prevalence of ADHD in school-age children in Egypt.11 They reported prevalence of ADHD about 21% that is higher from finding of present study. This difference can be related to difference in social and cultural difference between samples of two studies. Also, instruments that used in two studies are different. For managing ADHD, detecting in earlier stage is crucial. For this reason, parents and teachers should be aware of this. However studies in this regards showed that they have not enough knowledge. In one study in this regards in 2006, Ghanizadeh et al. examined the knowledge and attitudes towards ADHD among elementary school teachers. Ghanizadeh et al. showed that knowledge of teachers about ADHD was relatively low. The main sources of knowledge about ADHD teachers in Ghanizadeh et al. were television and radio, friends and relatives, newspapers and magazines.8
With regards to risk factors, most previous studies showed similar finding. Shahigavad et al. assessed the disorder in primary school students in Shiraz-Iran. They found a significant difference between the prevalence of the disease in boys and girls with higher prevalence in boys.13 Results also indicate that there is no significant relation between the prevalence of ADHD and the grade of samples. The same result was found in the study accomplished by Tavangar in primary schools of Yazd-Iran.14
Another finding showed that there was a significant relation between health statuses of samples with the existence of a family history of the disease since 15.5% of patients had a positive family history. The study of Hebrani et al. concluded that higher prevalence in patients' families indicates a strong genetic factor for the disorder. They added that the presence of accompanied disorders in patients and the high prevalence of mood and anxiety disorders in the family of these patients can indicate a common genetic background between these disorders and some of their subgroups.9
Results also showed that there is a significant relation between hyperactivity disorder and job of mother. In this study, majority of mothers (12.8%) were housewives. Brandi found the same relation in his study. He found that the highest prevalence was seen in the children of mothers with non-governmental jobs (6.5%), and the lowest were in those with governmental jobs.15
Another finding was a significant relation between the disorder and the number of children in the family with highest rate in families having four children and more. Burger et al. found that families with four or more children (47.1%) show highest rate of the disease.16 Findings indicate that there is no relation between the number of female children in the family and the birth order and the incidence of the disorder. In the study of Miller such a relation was not observed similarly.14 This study showed no significant relation between the kind of dwelling of the samples and the disorder. In the same way, Ballsterinoet al. did not find any relation between the mentioned factor and the disorder.17 Results also showed that there is no relation between the number of male children in the family and the incidence of the disease, but there was a significant relation between parents' level of education and the prevalence of the disorder where families with parents of lower educational level (high school and lower levels) showed more prevalence rate.
This study showed that prevalence of ADHD in primary school students in Hamadan is high. Factors such as, sex, number of children in family, parent level of education, and family income increased this rate. A close collaboration between schools' authorities and parents is recommendable, and the early diagnosis is crucial.
CONFLICT OF INTEREST
There is no Conflict of interest in this study.
We are very grateful of the deputy of research in Hamadan University of Medical Education as well as parents of the children and authorities in education and training department of Hamadan city.
1. Suzan G. Pediatric training. Translated to Persian by: Javari Z. Tehran: saran Institute; 2004: 386-402.
2. Kafka M. Henan J. Psycho stimulant augmentation during treatment with in children. J Clin Psychiatry. 2008; 61(9): 640-70.
3. SSRI G, Stuart W, Sundown S. Psychiatric Nursing. 6th ed. USA: Mosby Co; 2007: 749-761.
4. Nelson B. Text Book of Pediatrics 18th. 1st ed. USA: Saunders Company; 2006: 110-123.
5. Abdekhodaie Z, Tabatabaei SM, Gholizadeh M. The investigation of ADHD prevalence in kindergarten children in northeast Iran and a determination of the criterion validity of Conners' questionnaire via clinical interview. Res Dev Disabil. 2012; 33(2): 357-61.
6. Goyette CH, Conners CK, Ulrich RF. Normative data on revised Conners Parent and Teacher Rating Scales. J Abnorm Child Psychol. 1978; 6(2): 221-36.
7. Jafari P, Ghanizadeh A, Akhondzadeh S, Mohammadi MR. Health-related quality of life of Iranian children with attention deficit/hyperactivity disorder. Qual Life Res. 2011; 20(1): 31-6.
8. Ghanizadeh A, Bahredar MJ, Moeini SR. Knowledge and attitudes towards attention deficit hyperactivity disorder among elementary school teachers. Patient Educ Couns. 2006; 63(1-2): 84-8.
9. Hebrani P, Abdolahian E, Behdani F, Vosoogh I, Javanbakht A. The prevalence of attention deficit hyperactivity disorder in preschool-age children in Mashhad, north-East of Iran. Arch Iran Med. 2007; 10(2): 147-51.
10. Alizadeh H, Armion E, Coolidge FL, Flores ZD, Sutton CE. The Prevalence of Attention-Deficit/Hyperactivity Disorder among Primary School Students in an Iranian Rural Region. Psychol. 2015; 6(3): 263-8.
11. Aboul-Ata MA, Amin FA. The Prevalence of ADHD in Fayoum City (Egypt) Among School-Age Children: Depending on a DSM-5-Based Rating Scale. J Atten Disord. 2015.
12. Zhou KY, Gao MH, Yang CH, Zhang JN, Chen YZ, Song JZ, et al. [An epidemiological survey of attention deficit hyperactivity disorder in school-age children in Shenzhen]. Zhongguo Dang Dai Er Ke Za Zhi. 2012; 14(9): 689-92.
13. Shahigavad A. Survey of ADHD in Shiraz school children. Sharghtabib. 2010: 7(4): 61-65.
14. Miller C. ADHD disorder in child hood. Nursing Consult. 2008; 63(7): 1570-5.
15. Brandi E. Parenting practices and ADHD” New finding suggest partial specificity of effects. J Prof Nurs. 2005; 21(3): 150-8.
16. Berger I, Felsenthal-Berger N. Attention-deficit hyperactivity disorder (ADHD) and birth order. J Child Neurol. 2009; 24(6): 692-6.
17. Loe IM, Balestrino MD, Phelps RA, Kurs-Lasky M, Chaves-Gnecco D, Paradise JL, et al. Early histories of school-aged children with attention-deficit/hyperactivity disorder. Child Dev. 2008; 79(6): 1853-68.