|Year : 2019 | Volume
| Issue : 2 | Page : 118-125
Prevalence of attention-deficit hyperactivity disorder in India: A systematic review and meta-analysis
Johny Kutty Joseph, Babitha K Devu
Faculty of Nursing, Shri Mata Vaishno Devi College of Nursing, Reasi, Jammu and Kashmir, India
|Date of Web Publication||21-Jan-2020|
Mr. Johny Kutty Joseph
Assistant Professor, Shri Mata Vaishno Devi College of Nursing, Kakryal, Katra, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Attention-deficit hyperactivity disorder (ADHD) is one of the popular neurological developmental disorders among children, adolescents, and even in adults. It is manifested by difficulty in attention, hyperactivity, and impulsiveness. ADHD and impulsivity can hinder in the school life, attaining goals, different abilities, and competitions of the student. There is ample literature reporting the prevalence of ADHD in the most part of the world. However, the prevalence of ADHD is not clearly understood in India. Many studies have been conducted in India to estimate the prevalence of ADHD in different parts of the country, but no attempt has yet been done to draw a conclusion on the pooled prevalence of ADHD in India. The goal of this study is to review all the available observational studies on the estimation of prevalence of ADHD among children and adolescents from different parts of the country to calculate the pooled prevalence of ADHD in India (among children and adolescents). The search also was limited to studies conducted from 2009 to 2019. All the epidemiological survey related to ADHD prevalence was included in the study after considering the inclusion criteria. Articles were reviewed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Each individual study was assessed for risk bias using the “Quality assessment checklist for prevalence studies” extracted from Hoy et al. Pooled Prevalence estimates was calculated with random effect model. The point prevalence of ADHD among children and adolescents in the included studies ranges from 1.30% to 28.9%. The pooled prevalence of ADHD among children and adolescents is 7.1% (95% confidence interval [CI]: 5.1%–9.8%). The summarized prevalence of ADHD is 9.40% (95% CI 6.50%–13.30%; I2 = 96.07% P < 0.001) among male children and 5.20% (95% CI 3.40%–7.70%; I2 = 94.17% P < 0.001) among female children with a range of 7.6%–15% in 8–15 years of children. The prevalence of ADHD among children in India is consistent with the worldwide prevalence. According to the ADHD Institute, Japan the world prevalence of ADHD ranges from 0.1% to 8.1%. This explains that ADHD affects quite a large number of children in India. As India is known for stigma related to mental disorders understanding the prevalence of ADHD in Indian Population helps to gain an insight into morbidity burden of the country and helps the parents and teachers to take care of the persons suffering from ADHD.
Keywords: Attention-deficit hyperactivity disorder burden in India, Indian scenario of attention-deficit hyperactivity disorder, prevalence of attention-deficit hyperactivity disorder
|How to cite this article:|
Joseph JK, Devu BK. Prevalence of attention-deficit hyperactivity disorder in India: A systematic review and meta-analysis. Indian J Psy Nsg 2019;16:118-25
|How to cite this URL:|
Joseph JK, Devu BK. Prevalence of attention-deficit hyperactivity disorder in India: A systematic review and meta-analysis. Indian J Psy Nsg [serial online] 2019 [cited 2020 Aug 11];16:118-25. Available from: http://www.ijpn.in/text.asp?2019/16/2/118/276353
| Introduction|| |
Attention-deficit hyperactivity disorder (ADHD) is one of the popular neurological developmental disorders among children, adolescents and even in adults. The children affected with ADHD commonly exhibit hyperactivity, inattention and/or impulsivity and are highly distractible and cannot contain their stimuli. ADHD and impulsivity can hinder in the school life, attaining goals, different abilities and competitions of the student. A number of studies have revealed supportive evidence of genetic influences in the etiology of ADHD. Certain neurotransmitters, namely nor epinephrine, dopamine and possibly serotonin are involved in the symptoms associated with ADHD.
The children with ADHD have poorer interpersonal, parent–child–sibling relationship, and less academic achievement in comparison to typically developing children, resulting in compromised self-esteem, inability to evaluate self, negative emotions, and so on. ADHD was primarily considered to be a disease affecting the children, but recent researches have proved that the symptoms of ADHD exist among adolescents and adults. Most of the studies have shown that hyperactivity gets reduced from childhood to adolescence, but the symptoms of ADHD such as inattention and impulsivity continue to be evident in adolescents and even to adulthood creating problems in interpersonal and family relationships.
Inattention and disorganization mean the failure to stay on task at levels that are conflicting with age or developmental stage, appearing not to listen, and losing resources. Hyperactivity/impulsivity involves over-activity, fidgeting, inability to sit down, intrusion into the activities of other people, and inability to wait, symptoms that are excessive for age or level of development. A major portion of children affected with ADHD face difficulties in performing age-related tasks and they are highly distractible. Impulsivity or deficit in inhibitory control is also common. According to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria the diagnosis of ADHD is based on symptoms of inattention, hyperactivity, and impulsivity that is persistent for at least 6 months. ADHD largely contribute to disturbed learning ability, antisocial behavior, road traffic accidents, sexual problems and crimes, among adolescence. This definitely creates serious negative effects on the society and family and hence become a major public health concern.
There is ample literature reporting the prevalence of ADHD in the most part of the world. However, the prevalence of ADHD is not clearly understood in India. Many studies have been conducted in India to estimate the prevalence of ADHD in different parts of the country but no attempt has yet been done to draw a conclusion on the pooled prevalence of ADHD in India. The goal of this study is to review all the available observational studies on the estimation of prevalence of ADHD among children and adolescents from different parts of the country in order to calculate the pooled prevalence of ADHD in India.(among children and adolescents).
Need of the review
ADHD has remained and remains as one of the most difficult conditions in psychiatry in diagnosis and categorization as evidenced by the frequent modification of the diagnostic criteria in the recent editions of DSM. Several systematic reviews have been done in the past to estimate the pooled prevalence of ADHD in different parts of the world. According to a recent Meta-Analysis on the prevalence of ADHD from studies done in Europe, it revealed that 7.2% (95% confidence interval [CI]: 6.7%–7.8%) children and adolescence have positive symptoms of ADHD. Another meta-analysis done in China reveals a pooled prevalence of 6.26% (95% CI: 5.36%–7.22%) ADHD among children. All these studies suggest that a vast number of children and adolescents are affected with ADHD worldwide leading to substantial burden on the society.
The investigators found that the western literature has considerably grown up in the prevalence, diagnosis, and management of ADHD; but, in India, few studies are done, and it is in the growing stage. In the past 10 years, a number of observation studies have been done to estimate the prevalence of ADHD among children in India. However, the prevalence estimated in number of studies is limited to certain geographical location and wide variability of the prevalence is also observed in the studies. For example, the prevalence in individuals aged between 6 and 18 years in Kashmir was 4.31%, whereas in individuals aged between 6 and 12 years in Bangalore, it was 2.3%, in individuals aged between 6 and 18 years in Odisha was 3.66%, in individuals aged between 10 and 16 years in New Delhi was 6.4%, in individuals aged between 6 and 11 years in Assam was 12.66%, and in individuals aged between 8 and 11 years in Tamil Nadu was 8.8%. Therefore, it is highly significant to analyze all the available data in an integrated manner so that a national prevalence of the disease burden can be estimated.
Recognition of the prevalence of ADHD among children and adolescents would help the clinicians in the early diagnosis of ADHD and that will minimize the adverse impact of this syndrome. On the other hand, the lack of knowledge regarding the epidemiological figures of this syndrome will lead to increased morbidity burden, developmental problems among children and adolescents, impaired family functioning, and also leads to comorbid psychiatric conditions such as ODD (oppositional defiant disorder), anxiety disorders, bipolar disorders, depression, conduct disorders, and substance abuse. This systematic review aims to critically review the existing studies with regard to the prevalence of ADHD in India so that the gap in data can be identified.
This systematic review aims to review the available observational studies on prevalence of ADHD among children and adolescents in India and find the pooled prevalence along with morbidity pattern and gender difference.
| Methods|| |
This systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.
We searched the literature using different keywords and combinations of keywords (Boolean operators) in data bases such as PubMed, EMBASE, Cochrane, Science Direct, Google Scholar, and other sources such as Research Gate, other direct websites. The search was limited to studies conducted in India. The search also was limited to studies conducted between 2009 and 2019 (10 years). The following search terms were used: ADHD Prevalence, ADHD burden, Epidemiology of ADHD, prevalence rate, adolescence, children. In addition, a manual search also was performed on the reference lists of all articles selected in the first step. All the epidemiological survey related to ADHD prevalence was included in the study after considering the inclusion criteria. The entire process was independently completed by two researchers.
Inclusion and exclusion criteria
The inclusion criteria were as follows: (1) original studies on the prevalence of ADHD among children (under 12 years) and adolescents (12–18 years); (2) sample obtained from the general population, school, and special homes; (3) cross-sectional or longitudinal studies; and (4) studies that are published and available for free access from 2009 to 2019. The exclusion criteria were as follows: (1) studies that did not report the prevalence of ADHD; (2) studies were done in the clinical/hospital setting of ADHD; (3) case reports, Editorials, and Reviews; and (4) Studies with incomplete or unclear information.
Using the predefined protocol, two researchers searched, collected, extracted, and evaluated the information from each individual study included in the review as per the inclusion criteria. The disagreements that occurred during the extraction of the data were resolved with mutual discussion and consultation with experts. The information extracted from the individual studies included; the name of the author including the year of publication, geographic location where the study was conducted, research design of the study, attributes of the samples such as age, sex and sample size, source of information/nature of research participants, the type of instrument uses for data collection and the result/estimated prevalence.
Few studies had other information regarding many psychiatric co-morbid conditions but the investigators have considered only data regarding prevalence of ADHD. The primary purpose of this meta-analysis was to estimate the pooled prevalence of ADHD among children and adolescence. As described in [Figure 1] 53.33% (16/30) studies did not possess the desired data and/or meet the inclusion criteria, and hence, they were excluded. In order to calculate the pooled estimate data from each selected studies were closely analyzed for the age of participants, tool of assessment of ADHD, source of information and methods used for collecting the data including the sex ratio. The details are given in [Table 1].
Assessment of risk bias
In the current review, each individual study was assessed for risk bias using the “Quality assessment checklist for prevalence studies.” The said checklist is extracted from Hoy et al. The tool composed 9 items to measure all dimensions of bias such as selection bias, measurement bias, and analytical bias. The summary of overall risk of study bias was interpreted as 0–3 (low risk), 4–6 (moderate risk) and 7–9 (high risk). As described in [Table 1], 11 studies selected for meta-analysis had low-risk bias and 03 studies had moderate-risk bias. Finally, the researchers, after thorough discussion, decided to add all 14 studies for meta-analysis.
Prior to the calculation of pooled prevalence all the data set of included studies were analyzed. The data was organized into prevalence of ADHD among male, mean age of ADHD in male, prevalence of ADHD among females, mean age of ADHD among females and total prevalence of ADHD among children and adolescence. The classification of data of each study is given in [Table 1]. All statistical analysis (meta-analysis) was performed using “Open-Meta (Analyst).” It is a completely open-source, cross-platform software for advanced meta-analysis. The pooled prevalence was estimated by entering the figures under population estimation mode using the input of sample size, number of events/ADHD cases and adding the lower and upper class intervals. In the current review, considering the heterogeneity between the studies with regard to sample selection, geographical location, instrument used for data collection a random effect model was adopted. The heterogeneity of the studies was calculated by estimating I2 (tau).
| Results|| |
Totally, 41 studies were identified following the initial search. After removing the duplicates 30 studies were potentially accepted for review. After reading and reviewing these studies 16 studies were removed considering the methodology and exclusion/inclusion criteria. Our main focus was to recognize the prevalence rate of ADHD in India and hence the studies were selected according to the inclusion criteria and the type of data available in each study. 65.6% (27) studies were not considered for analysis due to insufficient data, and related factors mentioned in the exclusion criteria. In order to calculate the pooled prevalence of ADHD in India 34.14% (14) studies were included [Figure 1].
Among the 14 studies included for the current systematic review and meta-analysis, 03 (21.42%) studies were assessed to have moderate risk of bias and 11 (78.57%) studies were assessed to have low risk. All the 14 studies were included in the Meta-analysis. 1 (07.14%) study collected data directly from the children, 01 (07.14%) from both children and teachers, 08 (57.14%) from both teachers and parents 02 (14.28%) collected data only from parents and 02 (14.28%) collected data only from teachers [Table 1].
Prevalence of attention-deficit hyperactivity disorder
The point prevalence of ADHD among children and adolescents in the included studies ranges from 1.30% to 28.9%. The pooled prevalence of ADHD among children and adolescents is 7.1% (95% CI: 5.1% to 9.8%). The analysis also showed significant heterogeneity among the selected studies (I2 = 97.06%, P < 0.001) [Figure 2].
Additionally, the prevalence rate of ADHD based on gender was also analyzed. The summarized prevalence of ADHD is 9.40% (95% CI 6.50% to 13.30%; I2 = 96.07% P < 0.001) among male children and 5.20% (95% CI 3.40% to 7.70%; I2 = 94.17% P < 0.001) among female children. With regard to the age of prevalence of ADHD among children and adolescents ranges from 8 to 15 years among male children and 7.6–15 years among female children. Two studies (Mohammad Maqbool Dar et al. and Himani Mahesh Joshi et al.) were not included in the analysis to summarize the prevalence of ADHD among children and adolescents with regard to their age and gender as significant data was not available in the mentioned studies.
| Discussion|| |
Currently, there are no nationwide data with regard to the prevalence of ADHD among children and adolescents in India. This systematic review and meta-analysis conducted to review the cross-sectional studies done in the past for 10 years (2009–2019). Very few studies could be added in the systematic review and meta-analysis due to the scarcity of the resources. The review included 14 studies comprising of 20143 people (children and adolescents).
The pooled prevalence of ADHD among children and adolescents is 7.1% (95% CI: 5.1% to 9.8%). The prevalence calculated by the current review is consistent with another review done in the neighboring country China. According to Wang et al. the point prevalence of ADHD reported in the included studies ranged from 0.73% to 14.40% with a pooled prevalence of 6.26% (95% CI: 5.36-7.22%). According to another study the overall mean of worldwide prevalence of ADHD is 2.2% (range: 0.1-8.1%) has been estimated in children and adolescents (aged < 18 years). According to Polanczyk G et. al the overall worldwide prevalence of ADHD among individual below 18 years of age is 5.29%.
The summarized prevalence of ADHD is observed more among males 9.40% (95% CI 6.50% to 13.30%; I2 = 96.07% P < 0.001) than females 5.20% (95% CI 3.40% to 7.70%; I2 = 94.17% P < 0.001). This is consistent with the finding of another study by Ramtekkar et al. which also explains the prevalence of ADHD among males (12.58%) is more than that among the females (5.52%). The age of prevalence of ADHD among children and adolescents ranges from 8 to 15 years among male children and 7.6–15 years among female children and this consistent according to Ramtekkar et al. which notes the mean age of ADHD is 7–12 years.
Further, it was also observed that the differences in the instrument and diagnostic criteria of ADHD among children and adolescents by various researchers also influenced the result of the study. The prevalence of ADHD among children and adolescents in different epidemiological studies may be overestimated or underestimated as the researchers used different scales and instruments to observe the phenomena. The geographical location of the study is also a major factor in the determination of the prevalence of ADHD among children and adolescents and in this review only few studies from selected Indian States were included due to the limited availability of quality scientific studies.
| Conclusion|| |
The prevalence of ADHD among adolescents and children in India is generally consistent with epidemiological figures across the globe with some exceptions. It is quite understood that ADHD causes a major morbidity burden on people under the age of 18 years and it alters the future life some people. The information from the current review may set a benchmark to assess the disease burden of the country and it will be a reference for resource planning, health care policymaking. However, a nationwide study with large number of studies is essential in this regard.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Townsend MC. Psychiatric Mental Health Nursing. 8th
ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2015 p. 714-24.
Lecendreux M, Konofal E, Faraone SV. Prevalence of attention deficit hyperactivity disorder and associated features among children in France. J Atten Disord 2011;15:516-24.
Zhang L, Jin X. Functional impairment of attention deficit hyperactivity disorder in children and adolescents. Chin J Pract Pediatr 2007;22:872-5.
Education Publication Centre. US Department of Education. Teaching Children with Attention Deficit Hyperkinetic Disorder: Instructional Strategies and Practices. Washington DC: Education Publication Centre; 2008.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders. DSM – V. 5th
ed. American Psychiatric Association; 2013.
Flory K, Molina BS, Pelham WE Jr., Gnagy E, Smith B. Childhood ADHD predicts risky sexual behavior in young adulthood. J Clin Child Adolesc Psychol 2006;35:571-7.
Malhi P, Singhi P. Spectrum of attention deficit hyperactivity disorders in children among referrals to psychology services. Indian Pediatr 2000;37:1256-60.
Thomas R, Sanders S, Doust J, Beller E, Glasziou P. Prevalence of attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Pediatrics 2015;135:e994-1001.
Wang T, Liu K, Li Z, Xu Y, Liu Y, Shi W, et al
. Prevalence of attention deficit/hyperactivity disorder among children and adolescents in China: A systematic review and meta-analysis. BMC Psychiatry 2017;17:32.
Bhatia MS, Choudhary S, Sidana A. Attention deficit hyperactivity disorder among psychiatric outpatients. Indian Pediatr 1999;36:583-7.
Dar MM, Hussain SK, Qadri S, Hussain SS, Fatima SS. Prevalence and pattern of psychiatric morbidity among children living in orphanages of Kashmir. Int J Health Sci Res 2015;5:53-60. Available from: https://www.ijhsr.org/IJHSR_Vol. 5_Issue. 11_Nov2015/9.pdf
. [Last accessed on 2019 Oct 21].
Catherine TG, Robert NG, Mala KK, Kanniammal C, Arullapan J. Assessment of prevalence of attention deficit hyperactivity disorder among schoolchildren in selected schools. Indian J Psychiatry 2019;61:232-7.
] [Full text]
Brook JS, Tseng LJ, Cohen P. Toddler adjustment: Impact of parents' drug use, personality, and parent-child relations. J Genet Psychol 1996;157:281-95.
Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, et al
. Assessing risk of bias in prevalence studies: Modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol 2012;65:934-9.
Ajinkya S, Kaur D, Gursale A, Jadhav P. Prevalence of parent-rated attention deficit hyperactivity disorder and associated parent-related factors in primary school children of Navi Mumbai – A school based study. Indian J Pediatr 2013;80:207-10. Available from: https://link.springer.com/article/10.1007/s12098-012-0854-1
. [Last accessed on 2019 Oct 19].
Venkata JA, Panicker AS. Prevalence of attention deficit hyperactivity disorder in primary school children. Indian J Psychiatry 2013;55:338-42. Available from: http://www.indianjpsychiatry.org/article
.asp?issn=0019-5545;year=2013;volume=55;issue=4;spage=338;epage=342;aulast=Venkata. [Last accessed on 2019 Oct 15].
Jaisoorya S, Beena KV, Beena M, Ellangovan K, George S, Thennarasuetal K. Prevalence and correlates of self-reported ADHD symptoms in children attending school in India. Attent Dis Sage J 2016;1-5. Available from: https://journals.sagepub.com/doi/10.1177/1087054716666951
. [Last accessed on 2019 Oct 23].
Manjunath R, Kishor M, Kulkarni P, Shrinivasa BM, Sathyamurthy S. Magnitude of attention deficit hyper kinetic disorder among school children of Mysore city. Int Neuropsychiatr Dis J 2016;6:1-7.
Suthar N, Garg N, Verma KK, Singhal A, Singh H, Baniya G. Prevalence of attention-deficit hyperactivity disorder in primary school children: A cross sectional study. J Indian Assoc Child Adolesc Ment Health 2018;14:74-88. Available from: http://www.jiacam.org/1404/orig4Oct2018.pdf
. [Last accessed on 2019 Oct 20].
Fayyad J, Sampson NA, Hwang I, Adamowski T, Aguilar-Gaxiola S, Al-Hamzawi A, et al
. The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord 2017;9:47-65.
Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: A systematic review and metaregression analysis. Am J Psychiatry 2007;164:942-8.
Ramtekkar UP, Reiersen AM, Todorov AA, Todd RD. Sex and age differences in attention-deficit/hyperactivity disorder symptoms and diagnoses: Implications for DSM-V and ICD-11. J Am Acad Child Adolesc Psychiatry 2010;49:217-80.
[Figure 1], [Figure 2]