Egyptian Journal of Psychiatry

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 39  |  Issue : 3  |  Page : 105--108

Screening for attention-deficit hyperactivity disorder among high-school graduates accepted for enrollment at Alexandria Faculty of Medicine: academic year 2016/2017


Ayat Eltayar1, Iman Diab2, Heba Elweshahy3, Hesham Sheshtawy4, Abd Elrahman Sharaf5,  
1 Department of Medical Education, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Department of Medical Education and Medical Biochemistry, Faculty of Medicine, Alexandria University, Alexandria, Egypt
3 Department of Medical Education and Community Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
4 Department of Medical Education, Neurology and Psychiatry, Faculty of Medicine, Alexandria University, Alexandria, Egypt
5 Department of Medical Education, Faculty of Medicine, Alexandria University, Alexandria; Department of Physiology, GUC, Cairo, Egypt

Correspondence Address:
Hesham Sheshtawy
Neuropsychiatry Department, El Hadra University Hospital, El Hadra, Alexandria 21525
Egypt

Abstract

Background Attention-deficit hyperactivity disorder (ADHD) is a prevalent and underdetected disorder with problematic consequences. Aim of the work The aim of this study was to study the prevalence of ADHD in first-year medical students before their start of academic work. Participants and methods A comprehensive survey of all high school graduates accepted for enrollment at Alexandria Faculty of Medicine for the academic year 2016/2017 was conducted using validated Arabic version of Adult Self-Report Scale screener questionnaire. Results Response rate was ∼93% (779 students). Screening of enrolled students for ADHD using Adult Self-Report Scale showed that nearly one-fifth (21.8%) had symptoms highly suggestive and another fifth (20.3%) were borderline. No significant difference was present between males and female students regarding their scores. Positive screening was not related to sex difference, residency, or type of school. Conclusion ADHD is prevalent among first-year medical students even before starting their academic study. Positive screening was not related to sex difference, residency, or type of school. Further follow-up is needed to discover the effect of positive screening on academic achievement.



How to cite this article:
Eltayar A, Diab I, Elweshahy H, Sheshtawy H, Sharaf AE. Screening for attention-deficit hyperactivity disorder among high-school graduates accepted for enrollment at Alexandria Faculty of Medicine: academic year 2016/2017.Egypt J Psychiatr 2018;39:105-108


How to cite this URL:
Eltayar A, Diab I, Elweshahy H, Sheshtawy H, Sharaf AE. Screening for attention-deficit hyperactivity disorder among high-school graduates accepted for enrollment at Alexandria Faculty of Medicine: academic year 2016/2017. Egypt J Psychiatr [serial online] 2018 [cited 2018 Oct 23 ];39:105-108
Available from: http://new.ejpsy.eg.net/text.asp?2018/39/3/105/243025


Full Text



 Introduction



It was initially thought that attention-deficit hyperactivity disorder (ADHD) remits in all children (Ross and Ross, 1976). However, 10–66% of ADHD cases may persist into adulthood (Biederman, 1998; Faraone et al., 2006). Approximately 4.4% of adults (18–44 years) meet the criteria to be diagnosed with ADHD (Kessler et al., 2006), and 3–6% of adults have ADHD-like symptoms that interfere with daily life (Kates, 2005). ADHD can be comorbid with mood and anxiety disorders (Biederman, 1998). Approximately 77–87% of adults with ADHD have at least one other comorbid psychiatric disorder (Biederman et al., 1993; McGough et al., 2005).

The diagnostic criteria for ADHD were designed for children and do not completely apply to adults (Davidson, 2008). The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association, 2000) has divided ADHD into three subtypes: ADHD predominantly inattentive type, ADHD predominantly hyperactive–impulsive type, and ADHD combined type. These three types have the same core features: symptoms dating back to childhood, impairment in at least two settings (home, work, school, and social), and moderate severity ratings for six of nine hyperactivity/impulsivity symptoms.

These criteria are criticized for not taking into consideration the developmental changes that happen as a person ages (Barkley, 1998). The criteria were created based on children (Riccio et al., 2005) without validation in adults (Heiligenstein et al., 1998; Riccio et al., 2005; Belendiuk et al., 2007) and leave out symptoms such as procrastination, poor motivation, and time-management difficulties (Davidson, 2008). DSM-IV criteria did not adequately distinguish between adults with ADHD and adults without ADHD (Murphy and Barkley, 1996). Approximately one-third of adults diagnosed with ADHD meet the DSM-IV ADHD criteria (McCann and Roy-Byrne, 2004). Because of the underdiagnosing of this condition, with its devastating consequences, what about the prevalence of adult ADHD in medical students?

 Aim of the study



This study aims at analyzing the prevalence of ADHD in first-year medical students before their start of academic work.

 Participants and methods



A comprehensive survey of all high school graduates accepted for enrollment at Alexandria Faculty of Medicine for the academic year 2016/2017 was carried out. Acceptance of students was basically done by the supreme council of Egyptian universities.

Students were approached on the days of obligatory pre-enrollment medical examination (3 consecutive days). Students younger than 18 years were excluded as a written consent should be obtained from their parents (n=41), rendering the number of eligible students equal to 876. Participation of students was voluntary. The response rate was 93.5%.

The validated Arabic version of Adult Self-Report Scale (ASRS) screener questionnaire (World Health Organization, 2014; Abd Elkarim et al., 2015) was revised and edited by psychiatric professionals to best fit the first-year medical students at Alexandria faculty of medicine. ASRS screener is a six-item questionnaire for screening adult ADHD. The form contains six questions found to be the most predictive of symptoms consistent with ADHD. Each question is to be answered on a five-point rating scale (never, rarely, sometimes, often, and very often). The student is asked to complete the checklist by marking an X in the box representing the scale point that most closely represents the frequency of occurrence of each of the symptoms. If four or more marks appear in the darkly shaded boxes, then the student has symptoms highly consistent with ADHD in adults, and further investigation is warranted (Kessler et al., 2007).

 Results



Baseline characteristics of studied students (n=779)

[Table 1] describes the baseline characteristics of studied students. More than a half of screened students (57.8%) are girls. The majority of them (92.3%) were aged 18 years, with only 7.7% of them being 19 years of age.{Table 1}

Nearly two-thirds (63%) of students were from outside Alexandria, and only 37% of students were from Alexandria. Regarding the place of living in Alexandria, 55.1% of them lived with their family, nearly two-fifths (42.5%) were residing in the student university hostel, and a minority lived alone or with his/her relatives.

Most studied students (93.5%) were graduates from governmental secondary schools. Only 6.6% of medical students studied from private schools.

No statistically significant difference was found between both male and female students regarding any of the previous characteristics.

Prevalence of attention-deficit hyperactivity disorder

Screening of enrolled students for ADHD using ASRS showed that nearly one-fifth (21.8%) had symptoms highly suggestive and another fifth (20.3%) were borderline. No significant difference between was found males and female students regarding their scores ([Table 2]). Positive screening was not related to sex difference, residency, or type of school.{Table 2}

 Discussion



In Egypt, students with high marks in final secondary examination have the opportunity to join medical faculty. After joining medical faculty, some of the students start to complain of new appearance of concentration difficulties that can lead to negative effect on their academic achievements. Can ADHD be (to some extent) responsible for this problem? Let us say even before that, can these students (with their high marks) have ADHD? Can these students have ADHD in ‘masked’ form before joining the faculty? Therefore, this current study examined the students before the start of their first academic year.

Screening of enrolled students for ADHD using ASRS showed that 21.8% were considered as having positive results for screening of ADHD and 20.3% were borderline.

Rohde et al. (1999) screened 1013 Brazilian students aged 12–14 years for ADHD using an instrument based on the 18 DSM-IV ADHD symptoms. They reported that the prevalence of positive ADHD was estimated to be 5.8%. The difference between the current study results and that of Rohde et al. (1999) can be related to differences in screening method and the age of the study groups.

Moreover, Tuttle et al. (2010) reported that 5.5% of medical students reported being diagnosed with ADHD and 72.2% of those students were diagnosed after the age of 18 years. Tuttle et al. (2010) depended on students’ reporting of being diagnosed with ADHD (not on a screening tool like the current study). So, some of the students who reported absence of ADHD can be unaware of being affected by it.

Atwoli et al. (2011) studied the prevalence of self-reported ADHD symptoms among medical students in Eldoret, Kenya. They used a similar screening tool for the current study (ASRS). They found that the prevalence rate of self-reported ADHD was 23.7% (consistent with the results of the current study).

In a study of 1080 US college students, 12% of the entire sample had clinically significant levels of ADHD symptoms as measured using the ADHD Self-Report Scale, whereas only 2% had received a formal diagnosis of ADHD (Garnier-Dykstra et al., 2011). Do we have an actual difference between formal diagnosis and screened diagnosis of ADHD? Does formal diagnosis actually reflect the burden of the problem or can it lead to underdetection of ADHD? Do those with positive screening have poor academic achievement in relation to their mates with negative or borderline results? All these questions need further research.

 Conclusion



ADHD is prevalent among first-year medical students even before starting their academic study. Positive screening was not related to sex difference, residency, or type of school. Further follow-up is needed to discover the effect of positive screening on academic achievement.[22]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Abd Elkarim A, Salama H, Ibrahim S, Abo El Magd O (2015). Prevalence and characteristics of adult attention-deficit hyperactivity disorder among substance use inpatients. Egypt J Psychiatry 36:9–13.
2American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders : DSM-IV-TR. Washington, DC: Am Psychiatric Assoc.
3Atwoli L, Owiti P, Manguro G, Ndambuki D (2011). Attention deficit hyperactivity disorder symptom self-report among medical students in Eldoret, Kenya. Afr J Psychiatry (Johannesbg) 14:286–289.
4Barkley RA (1998). Attention deficit-hyperactivity disorder: a handbook for diagnosis and treatment. 2nd ed. New York, NY: Guilford.
5Belendiuk KA, Clarke TL, Chronis AM, Raggi VL (2007). Assessing the concordance of measures used to diagnose adult ADHD. J Atten Disord 10:276–277.
6Biederman J (1998). Attention-deficit/hyperactivity disorder: a lifespan perspective. J Clin Psychiatry 59:4–16.
7Biederman J, Faraone SV, Spencer T (1993). Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention-deficit/hyperactivity disorder. Am J Psychiatry 150: 1792–1798.
8Davidson MA (2008). ADHD in adults: a review of the literature. J Atten Disord 11:628–641.
9Faraone SV, Biederman J, Mick E (2006). The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 36:159–165.
10Garnier-Dykstra LM, Pinchevsky GM, Caldeira KM, Vincent KB, Arria AM (2011). Self-reported adult attention-deficit/hyperactivity disorder symptoms among college students. J Am Coll Health 59:133–136.
11Heiligenstein E, Conyers LM, Berns AR, Smith MA (1998). Preliminary normative data on DSM-IV attention deficit-hyperactivity disorder in college students. J Am Coll Health 46:185–188.
12Kates N (2005). Attention-deficit disorder in adults: management in primary care. Can Fam Physician 51:53–59.
13Kessler RC, Adler L, Barkley R (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 163:716–723.
14Kessler RC, Adler LA, Gruber MJ, Sarawate CA, Spencer T, Van Brunt DL (2007). Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members. Int J Methods Psychiatr Res 16:52–65.
15McCann BS, Roy-Byrne P (2004). Screening and diagnostic utility of self-report attention-deficit/hyperactivity disorder scales in adults. Compr Psychiatry 45:175–183.
16McGough JJ, Smalley SL, McCracken JT (2005). Psychiatric comorbidity in adult attention deficit- hyperactivity disorder: findings from multiplex families. Am J Psychiatry 162:1621–1627.
17Murphy K, Barkley RA (1996). Attention deficit hyperactivity disorder in adults: comorbidities and adaptive impairments. Compr Psychiatry 37:393–401.
18Riccio CA, Wolfe M, Davis B, Romine C, George C, Donghyung L (2005). Attention deficit-hyperactivity disorder: manifestations in adulthood. Arch Clin Neuropsychol 10:249–269.
19Rohde LA, Biederman J, Busnello EA, Zimmermann H, Schmitz H, Martins S et al. (1999). ADHD in a school sample of Brazilian adolescents: a study of prevalence, comorbid conditions, and impairments. Acad Child Adolesc Psychiatry 38:716–722.
20Ross DM, Ross SA (1976). Hyperactivity: research, theory, and action. New York, NY: John Wiley.
21Tuttle JP, Scheurich NE, Ranseen J (2010). Prevalence of ADHD diagnosis and nonmedical prescription stimulant use in medical students. Acad Psychiatry 34:220.
22World Health Organization (2014). Adult ADHD Self-Report Scale-V1.1 (ASRS-V1.1) Screener (Arabic version) from WHO Composite International Diagnostic Interview. Translated by Suaad Sayed Moussa, MD, Professor of Psychiatry, Kasr Alaini Medical School, Cairo University and Muhammad Nashaat, MSc, Assistant Lecturer of Psychiatry, Kasr Alaini Medical School, Cairo University