Attention Deficit/Hyperactivity Disorder among schoolchildren in Baghdad.

Dear Editor: A number of studies have examined the prevalence of ADHD in various countries. Variations in prevalence rates of ADHD exist between different studies due to such factors as the sources of information, assessment of clinical impairment, population characteristics, methodological features, ethnic and cultural differences and diagnostic criteria (Skounti et al., 2007). Studies of ADHD among school children yield prevalence rates ranging from 2.4% to 19%. Therefore the characterization of these factors is critical and the differences could throw light on identifying causative agents (Faraone et al., 2003). In children and adolescents the estimated male to female ratio is 4:1, and females tend to present as the predominately inattentive type, which may lead to underdiagnosis and undertreatment (Cantwell, 1996). Around 60% carry symptoms into adulthood (Schweitzer, 2001). Recognition of ADHD as a disorder affecting a significant percentage of children in many countries has important implications for their psychiatric care. Numerous studies have shown that appropriate management can significantly impact on the symptoms of ADHD and thus help children and their families live with or overcome the burden of this disorder (Multimodal Treatment Study Group, 1999). Studies on ADHD among children in the Arab countries are scarce (Al-Sharbati et al., 1998) despite the fact that the percentage of children and adolescents constitute a greater part of the total population, for example 40% in Egypt and 53% among Palestinians (UNICEF). The objective of this study was to quantify the rate of ADHD among schoolchildren in Baghdad, the capital city of Iraq where almost 50% of population are below 18 years of age. In 1999, formal consent was obtained from the education authority to examine schoolchildren at 8 elementary schools in Baghdad. Children had been screened using the Arabic version of DSM IV to diagnose ADHD. The sample consisted of 1043 children with an age range of 6 to 10 years, 529 (50.4%) were males and 517 (49.6%) were females. Both teachers and parents were involved in assessment and socio- demographic variables like age, sex, child rank in the family and parent’s level of education were reported. By using a scale based on DSM IV devised by local experts, teachers recorded that 110 (10.5%) out of the total sample of 1043 children had symptoms of ADHD, the male: female ratio was 1.8:1. Of the total, 48% presented with combined type, 31% predominately hyperactive-impulsive type, and 21% predominately inattentive type. In a second step procedure, the same rating scale, modified for parents, was used, where parents reported 62 (5.9%) children with ADHD with a male:female ratio of 2.2:1. Combined type was found among 29 children. Predominately hyperactive-impulsive type was reported in 17 and 16 had the predominately inattentive type. In all subtypes males rates were nearly double the females’ rates. We concluded that ADHD exists in our country and with a similar clinical picture as reported by studies in other parts of the world. However as reported above there seems to be a relatively higher number of female students exhibiting ADHD symptoms and a discrepancy between teacher and parent ratings. The contribution of trauma in developing behavioural problems among children and adolescents is well recognised (Allwood et al., 2000). Iraqi children have been exposed to the severe adverse consequences of violence and instability. While speculative at this point, there could be a link between exposure to trauma and the higher relative female to male prevalence but further studies are needed to clarify this relationship. The higher prevalence in teacher ratings could be explained by teacher’s perceptions that children are more distractible as a result of trauma or other preoccupations they may have about their families. Alternatively, parents who are traumatized themselves may under report their own children’s difficulties. This study has yielded some important indicators about the presence of ADHD among children in Iraq. However, the UN embargo imposed on Iraq from 1990 to 2003 has impeded educational and scientific work including research and publication. In addition, factors such as low community awareness and the lack of will by the state government to provide funding for research and treatment has negatively impacted the mental health of Iraqi children, in turn impacting on Iraqi society. Sincerely,