Symptoms of attention deficit hyperactivity disorder ADHD among rural primary school children in southeastern Nigeria comparison of school and home settings

Niger J Paed 2015; 42 (4): 329 – 334

ORIGINAL

Ndukuba AC

Symptoms of attention deficit

Ibekwe RC

Odinka PC

hyperactivity disorder (ADHD)

Muomah RC

among rural primary school

Igwe MN

children in southeastern Nigeria:

Obindo JT

Omigbodun O

comparison of school and home

settings

DOI:http://dx.doi.org/10.4314/njp.v42i4.9

Accepted: 10th August 2015

Abstract : Background: Diagnosis

Results: Of the 18 symptoms of

of ADHD depends on manifesta-

the condition, there were signifi-

Ndukuba AC

(

)

tion of symptoms in at least two

cant differences in the rate of iden-

Odinka PC, Muomah RC

different settings. This therefore

tification in eight symptoms.

Department of Psychological Medicine,

University of Nigeria Enugu Campus

emphasizes the importance of

These symptoms include ‘being

Email: appolos.ndukuba@unn.edu.ng

multiple informants, parents and

easily distracted’ (p=0.0427),

teachers.

However

perception

‘difficulty following through on

Ibekwe RC

could differ because

of differ-

instruction’ (p=0.0026), ‘fails to

Department of Paediatrics,

ences and inconsistencies across

give close attention to details

Univeristy of Nigeria Teaching

different settings. This is particu-

(p=0.0001), ‘avoids tasks neces-

Hospital – Ituku Ozalla Enugu, Nigeria.

larly important in rural settings in

sary

for

tasks’

(p=0.0013),

Africa where the educational at-

‘difficulty

playing

quietly

Igwe MN

tainment and outlook of teachers

(p=0.0059),

‘talks

exces-

Department of Psychological Medicine,

Ebonyi State University Abakaliki,

are very different from those of

sively’ (p=0.0023), ‘intrudes on

Nigeria.

the parents.

others’ (p=0.0004), and ‘seems not

The study is aimed at comparing

to listen when spoken to di-

Obindo JT

the presentations of children with

rectly’ (p=0.0002). They were all

Department of Psychiatry,

ADHD in the rural area, across

consistently more manifest in

Jos University Teaching Hospital Jos,

two different settings: home and

school settings than in their homes.

Nigeria.

school.

Conclusion : Teachers identified

Methods:

The teachers

of 181

ADHD symptoms more commonly

Omigbodun O

rural primary school children in

than parents.

They could there-

Department of Psychiatry, University

College Hospital, Ibadan, Nigeria.

Ogberuru in Imo state, south east-

fore play critical roles in programs

ern, Nigeria completed the school

aimed at improving early identifi-

version of ADHD rating scale-IV,

cation and management of children

and their parents completed a

with ADHD especially in rural

Socio demographic questionnaire

Africa where healthcare facilities

and the home versions of the

are scarce.

ADHD rating scale-IV.

Introduction

African literature observed that the prevalence of ADHD

among African school children

range from 5.4% to

8.7%. Adewuya and Famuyiwa

Attention deficit hyperactivity disorder (ADHD) is a

in the Southwestern

and Ambuabunos et al

common childhood neurodevelopmental disorder with

in the South-south part of Nige-

serious consequences for the patients, their families and

ria reported prevalence of 8.7% and 7.6% respectively

the society . It is associated with tremendous financial

1,2

among

children in

urban school settings. In Benin

burden

and impairment in multiple domains of func-

City, Egbochuku and Abikwi

reported a prevalence of

tioning, maladaptive interpersonal interaction and low

23.15%

among school children.

There appear to be

self-esteem . As health care providers are becoming

3,4

variation in the prevalence of ADHD among Nigerian

increasingly aware of the burden ADHD places on the

children across the six geopolitical zones. Like most

health care system, ADHD is likely to become increas-

other African studies, these researchers explored the

. However, Ndukuba et al ,

urban centers

7, 10 -13

ingly important in primary health care .

re-

ported a rate of 6.6% in a population of rural school

Available data suggest that ADHD is prevalent among

children in Nigeria suggesting that children in rural ar-

Nigerian children. For instance, Bakare in a review of

eas are also prone to manifesting the disorder at a rate

330

comparable with those in the urban centers.

Nigeria.

The diagnosis of this condition relies on the identifica-

tion of the symptoms in multiple settings. In both DSM-

Sample

IV (and DSM 5

the symptoms of ADHD have to be

present in at least two different settings for the diagnosis

A sample size of 200 children was calculated based on a

to be made

15,16

. This recognizes the fact that this condi-

prevalence rate of 5%, allowing for 20% attrition rate.

tion could present differently and inconsistently across

All school children in the community were eligible to be

different settings. The ability to recognize the symptoms

enrolled in the study but only those who were selected

of this condition in the different settings therefore could

and whose parents consented to the study were included

affect early diagnosis and treatment of the disorder.

in the study.

With reliability of child self-report before the age of

nine being questionable and even when over the age of

Instruments

ten, they are found to report more of internalizing symp-

toms and underplay the externalizing ones . There is

The instruments used in the study included a Socio

therefore need to obtain information from adults who

demographic questionnaire designed by the authors to

have significant contacts with the ADHD child espe-

collect information such as age, gender, religion, domi-

cially as no laboratory investigation for now clearly

cile, family size, birth order, and parental educational

identifies children with this condition.

level and the school and home versions of the ADHD

rating scale-IV.

Early identification and early intervention for children

with this condition is of paramount importance given the

The school and home versions of ADHD Rating Scale-

IV was developed by DuPaul et al

serious negative consequences of this condition on the

and has been

child and the family. This in turn depends on the keen-

shown to have adequate psychometric properties for use

ness of the observation of the child’s behaviour by the

as screening, diagnostic and treatment outcome meas-

adults that live and interact with the child. These adults

ures. It is an 18-item instrument in a 4-point Likert scale

are bound to relate differently with them and often vary

(not at all, just a little, pretty much and very much, with

in their responses to the child’s behaviour and thus dif-

scores 0, 1, 2 and 3 respectively). The items of the ques-

fer in the symptoms which they observe. These differ-

tionnaire reflect the Diagnostic and Statistical Manual

ences could influence the rate at which the symptoms of

for Mental Disorders (DSM-IV) items for the diagnosis

this condition are identified in the different settings. It

of the condition. The authors of the instrument have

has been reported that the degree of agreement among

developed norms for the scores. This study adopted the

these adult informants is far from being perfect

and

method of interpretation given by the authors of the

this has serious consequences for the early identification

manual, in which a symptom endorsed to be ‘pretty

and treatment of children with ADHD. It remains an

much’ or ‘very much’ present is adjudged to be present.

issue when multiple informants are not available and

The instruments were pretested in 10 parents and 10

which informant carries more weight in the identifica-

teachers who were not part of the study respondents and

tion of the ADHD symptoms. There is therefore need to

they were found to have well understood the items on

evaluate the presentation of the disorder in the two ma-

the questionnaire. All the instruments were first, trans-

jor settings where most children in our environment

lated into Igbo language. Then, the Igbo versions were

naturally find themselves- the school and at home.

back-translated into English language by another trans-

lator who is fluent in both English and Igbo languages.

Despite the serious negative consequences of the symp-

The original and the back-translated English versions

toms of ADHD, very few studies have focused on the

were then compared and were found to be similar. Both

presentations of this condition in different settings espe-

versions of the instrument demonstrated good internal

cially in the rural areas where the majority of the popu-

consistency, with a Cronbach alpha of 0.89 for the

lation reside. This study aims to evaluate the presenta-

school version and 0.88 for the home version.

tions of this condition in two different settings – school

and home- by children manifesting with symptoms of

Procedure

this condition in a rural setting. It is hoped that this

study will contribute in understanding the presentation

Approval for the study was obtained from the ethical

of this condition especially among the rural dwelling

committee of the Jos University Teaching Hospital. The

children of Africa.

researchers also obtained the permission of the headmas-

ters of the schools and held two meetings with the teach-

ers. In the first meeting, the roles of the teachers in the

study were explained and their consent to participate

Methodology

was obtained. The teachers also practiced how to fill the

Design and setting

questionnaire with the right information about their pu-

pils, and clarifications were given on areas that were not

This study was a cross-sectional descriptive epidemiol-

very clear to them. This was done to ensure that they

ogical survey that was carried out in Ogberuru, a

understood the items on the questionnaire very well in

homogenous Igbo speaking rural community in Orlu

order to give the appropriate response to the questions.

Local Government Area of Imo State in the southeastern

The school teachers well understood all the items of the

331

instrument. In the second meeting, the children to be

Table 1: Family characteristics of participants

enrolled into the study were selected through balloting.

Variable

Frequency n (%)

In this process, ‘yes’ or ‘no’ were written on small

Family type

pieces of papers that were folded and pooled into an

Monogamous

157(86.7)

open-ended sack for them to pick from. Only those who

Polygamous

20(11.0)

picked the papers marked ‘yes’ were enrolled. Their

Single mother

4(2.3)

names were taken, and copies of the school version of

Family size

the ADHD Rating Scale IV were given to their teachers

Small (4 children and below)

26(14.4)

to complete. Letters requesting parents to come to the

Large (5 children and above )

155(85.6)

Living with

school with respect to the study were then distributed to

Both parents

118(65.2)

the selected school children. The authors also took time

Father

to talk to the parents of the pupils who were selected and

Mother

21(11.6)

who presented for the study about the illness and the

Grand parents

16(8.8)

relevance and nature of the study. Their informed con-

Other arrangements ( Uncles, aunts etc)

26(14.4)

sent to participate in the research was obtained.

Parents assessment of health of marriage

Very poor

7(3.9)

After obtaining the informed consent from the parents,

Poor

28(15.5)

they were then interviewed with the Socio demographic

Good

74(40.9)

Very good

40(22.1)

questionnaire, and the home version of the ADHD Rat-

No comment

32(17.7)

ing scale-IV. The preferred version (Igbo or English) of

the questionnaires were administered by ACN, who is

Twelve (6.6%) parents had no formal education, while

fluent in both Igbo and English languages. Home visits

42(23.2%), 87(48.1), 31(17.1%), 9(5.0%) of the parents

were scheduled to reach those parents who did not turn

had primary, secondary, tertiary and other job specific

up for the school visits. The parent information was ad-

forms of education respectively. One hundred and

judged to be unavailable when the parent could not be

eleven (55.8%) of the mothers had at least a secondary

reached after three visits.

education while 10(5.5%) of them had no form of

education.

Data analysis

The prevalence of the individual ADHD symptoms in

the two settings is as shown in table 2. In both home and

The data collected, which were double-checked for ac-

school settings, the least frequently identified symptom

curacy were analyzed using the GraphPad Prism ver-

was “seems not to listen when spoken to directly” which

sion 5. Chi-square tests were used to test the differences

was identified by 9.8% of the parents. This symptom

between categorical variable and their associations in a

was significantly more identified at school, with 41

cross tabulation.

(22.6%) of the teachers identifying it in the children

(p=0.0002).

The least identified symptom in the school setting is

Results

“loses things necessary for tasks, which was reported by

26(14.4%) of the teachers. Though more parents 34

One hundred and eighty-one participants, who were

(18.8%) identified this symptom at home, there is no

made up of 97(53.6%) boys and 84(46.4%) girls with a

significant difference in the expression of this symptom

mean age of 9.39 years (SD +/- 1.97), had both school

at home and in school (p=0.26).

and home information completed. The remaining 19 (11

At school, ” failure to give close attention to details”

boys and 8 girls) whose parents could not be reached

was significantly more commonly identified symptom of

were excluded from the analysis.

ADHD in the children, being reported by 72(39.8%) of

The modal age group was 6-8 years, and 42% of them

the teachers compared to 38(20.4%) of the parents

fell within this age group. All but four (2.2%) of the

(p=0.0001).

participants lived in the community where the study was

conducted. As shown in table 1, majority (86.7%) of the

At home, “often being forgetful” was the most com-

participants were from monogamous homes and most

monly identified symptom which was reported by 73

(65.2%) of them were living with both parents. None of

(40.4%) of the parents. There was however no signifi-

the participants lived with the father alone whereas 21

cant difference between the rate of identification in the

(11.6%) lived with the mother.

school and at home (p=0.5899).

Of the 18 symptoms of the condition, eight showed sig-

nificant differences in the two settings. There was sig-

nificant difference in the rate of symptom identification

between the parents and the teacher in nearly half of the

symptoms

which

included

‘being

easily

dis-

tracted’ (p=0.0427), ‘difficulty following through on

instruction’ (p=0.0026), ‘fails to give close attention to

details’ (p=0.0001), ‘avoids tasks necessary for

tasks’(p=0.0013), ‘difficulty playing quietly’(p=0.0059),

‘talks excessively’ (p=0.0023), ‘intrudes on oth-

332

ers’ (p=0.0004), and ‘seems not to listen when spoken to

outcomes and guide management of the affected chil-

dren

19,20

directly’ (p=0.0002).

Five out the eight symptoms which showed difference in

The finding in this study that more of the symptoms of

their identification in the two settings were from the

this condition were identified by teachers could reflect

inattentive group while three were from the hyperactive

the comparative advantage of the teachers over the par-

impulsive group. Of the remaining 10 symptoms which

ents in observing children with abnormal behaviours

did not show any difference in the two settings, six of

since having children of same developmental level in the

them were from the hyperactive impulsive group while

class provides them with the opportunity to compare

four were from the inattentive subtype. Across all these

their behaviours. This most likely is in addition to the

symptoms, the teachers were more likely than parents to

teachers being relatively more equipped than parents in

identify them in the children.

identifying children with challenges by virtue of their

training and experience.

Table 2: Prevalence of individual ADHD symptom in school

and home setting

The differences in the identification of the symptoms in

Symptom

School

Home

P –

the two settings could reflect the varying responses of

setting

value

the adults to the behaviours of the impaired children.

n(%)

The symptoms of inattention and hyperactivity nega-

Often fidgets

34(18.7)

30(16.6)

0.5816

Difficulty remaining seated

37(20.4)

25(13.8)

0.0941

tively impact many areas of functioning including the

Easily distracted

48(26.5)

32(17.7)

0.0427*

academic activities of the impaired child, which Abik-

Difficulty awaiting turn in

recognized and suggested ways of helping children

groups

36(19.9)

28(15.5)

0.2704

with such problems in the classroom setting.

Blurts out answers

38(21.0)

25(13.8)

0.0715

Difficulty following through on

The nature of the symptoms could have contributed to

instruction

59(32.5)

34(18.8)

0.0026*

the variation in identifying the symptoms of ADHD in

Difficulty sustaining attention

42(25.4)

38(20.4)

0.6124

the two settings. For instance, this study finds that par-

Fails to give close attention to

ents in this study tended to identify more of the children

details

72(39.8)

38(20.4)

0.0001*

Avoids tasks requiring sustained

who lose things necessary for tasks and are often forget-

mental effort

60(33.2)

31(17.1)

0.0013*

ful. The implications of the symptoms for the setting

Difficulty playing quietly

42(23.2)

22(12.2)

0.0059*

such as costs of replacing the lost items incurred by par-

Talks excessively

47(25.9)

24(13.2)

0.0023*

ents would make them to more readily identify this

Intrudes on others

46(25.4)

20(11.1)

0.0004*

Seems not to listen when spoken

symptom. It is, therefore, likely that the implications of

to directly

41(22.6)

15(9.8)

0.0002*

the symptom for the adult caregiver (parent or teacher)

Loses things necessary for tasks

26(14.4)

34(18.8)

0.2582

influences the identification of the symptoms as prob-

On the go as if driven by a

lems.

motor

35(19.4)

23(12.7)

0.0855

Often forgetful

68(37.6)

73(40.4)

0.5899

Runs about excessively

30(16.8)

19(10.5)

0.0910

This study finds that most of the symptoms that showed

Difficulty organizing tasks

58(36.0)

43(23.7)

0.2481

significant differences in the two settings were from the

inattentive groups of symptoms and all of them were

more identified by teachers than the parents. It is likely

that teachers were more likely to identify inattentive

Discussion

symptoms in the children because of the more enduring

negative impact of these symptoms on the classroom

Attention deficit hyperactivity disorder (ADHD) is a

activities, which the parents do not have the opportunity

disorder that manifests in childhood with symptoms of

of experiencing with their impaired children. That the

hyperactivity, impulsivity, and/or inattention. The symp-

more disruptive and highly externalizing hyperactive-

toms affect cognitive, academic, behavioral, emotional,

impulsive symptoms are usually obvious to most people

and social functioning.

It manifests with symptoms of

and thus were readily identified by both parents and

hyperactivity, impulsivity and/or inattention. The symp-

teachers. This could account for not having significant

toms manifest in various settings and negatively impact

differences in the identification of these groups of symp-

many aspects of the individuals’ life including academ-

toms in both settings. The preponderance of male gen-

ics difficulties, social skills problem and strained rela-

der in clinic based studies have been attributed to refer-

tionships. That both parents and teachers readily identi-

ral bias among others and the male:female prevalence

fied the symptoms of this condition in the children re-

ratio is found to obliterate in most community based

flects the pervasiveness of the symptoms of this

studies. This obliteration is attributable to capturing the

disorder.

more inattention symptoms of the disorder in the com-

munity based studies.

The study however finds some variation in the presenta-

tion of the symptoms in the two settings. While most of

Considering that girls with ADHD are reported to have

the symptoms were more identified in the school setting,

more intellectual impairment

and were more likely to

some of them tended to be more identified by the par-

have behavioural problems such as substance abuse

ents. This variation underscores the need for collabora-

and these girls were more likely to present with the more

tion among the parents, the child, and the school staff,

internalizing inattention symptoms.

22-24

It is obvious

which has been identified as being very important in

that the nature of symptoms manifested by children with

identifying appropriate target symptoms and functional

333

ADHD has serious outcome implications. This study

entire country or people of south-eastern Nigeria. The

reports inattention symptoms to be more reported in

number of children studied is relatively small. The use

school setting. Since diagnosis of this condition depends

of only one instrument for the assessment of ADHD in

on the report of various informants, the finding of this

the children is also a limitation in this study. However,

study suggests that serois weight should be given to the

assessing both parents and teachers is strength of the

observations made at school.

study. The Igbo versions of the instruments that were

used were not standardized, and this could affect the

result of the study. Direct observation of the children’s

behaviour in the settings would further improve the

Conclusion

quality of the study.

This study highlights the significance of multiple infor-

Authors’ contributions

mants in evaluating children with ADHD and the need

CAN and PCO conceived the study,

for collaboration and communication between homes

ACN, RCI and MNI designed the study.

and schools in the early identification of children with

CAN, RCM, JTO and OO collected the data.

this problems. With the teachers identifying ADHD

ACN and RCI did the data analysis. All the authors

symptoms more commonly than parents, they could

wrote, edited and approved the final manuscript.

play critical roles in programs aimed at improving early

Conflict of Interest: None

identification and management of children with ADHD

Funding: None

especially in rural Africa where healthcare facilities are

scarce.

Limitations

The results of this study cannot be generalized to the

References

Benjasuwantep B, Rwangdara-

Adewuya A O, Famuyiwa O O.

13. Wait J W, Stanton L, Schoeman J

ganon N, Visudliphan O. (2002).

Attention deficit hyperactivity

F. Tuberculosis meningitis and

Prevalence and clinical character-

disorder among Nigerian primary

attention deficit hyperactivity dis-

istics of attention deficit hyperac-

school children: prevalence and co

order in children. J Trop Pediatr

tivity disorders among primary

-morbid conditions. Eur Child

2002; 48(5): 294 – 299 .

school students in Bangkok. J.

Adolesc Psychiatry 2007; 16 (1):

14. Zeeger I, Rabie H, Swanevelder S,

Med Assoc Thai 2002; 85(suppl

10-15.

Edson C, Cotton M, VanToorn R.

4): S1232-40.

Ambuabunos E A, Ofovwe E G,

Attention deficit hyperactivity and

Sayal, K., Taylor, E., Beechan, J.,

Ibadin M O. Community survey of

oppositional defiance disorder in

Bryne, P. (2002). Pathways to care

attention deficit/hyperactivity dis-

HIV-infected South African chil-

in children at risk of attention

order among primary school chil-

dren. J Trop Pediatr,2010; 56 (2):

deficit hyperactivity disorder. BJP

dren in Benin City, Nigeria. Ann

97 – 102.

2002; 181: 43-48.

Afr Med 2011; 10(2): 91-6.

15. Ndukuba A C, Odinka P C,

Broadbent J M, Ayers KM,

10. Egbochuku E O, Abikwi MI. The

Muomah R C, Obindo J T, Omig-

Thomson W M. Is attention deficit

prevalence of attention deficit

bodun O O. Attention Deficit

hyperactivity disorder a risk factor

hyperactivity disorder (ADHD)

hyperactivity Disorder (ADHD)

for dental caries? A case control

among primary school pupils of

among rural southeastern Nigerian

study. Caries Res 2004; 38(1): 29-

Benin metropolis. J. Hum Ecol

primary school children: preva-

33.

2007; 22 (4): 317-322.

lence and psychosocial factors. J.

Busch B, Biederman J, Cohen G

11. Bakare M O, Ubochi V N, Ebigbo

Attention Disorders 2014 pii:

L et al. . Correlates of ADHD

PO, Orovwigho A O. Problem and

1087054714543367. [Epub ahead

among children in paediatric clinic

pro-social behaviour among Nige-

of print]

and psychiatric clinic. Psychiatr

rian children with intellectual dis-

16. American Psychiatric Association.

Services 2002; 53:1103-1111.

ability: the implication for devel-

Diagnostic and Statistical Manual

Tharpa A, Tharpor A . Is primary

oping policy for school based men-

of Mental Disorders. 4th ed.

care ready to take on attention

tal health programs. Italian J Pedi-

Washington DC. American Psychi-

deficit hyperactivity disorder?

atr 2010;36: 37.

atric Association; 1993 .

BMC Family Practice 2002; 3: 7.

12. Kashala E, Lundervold A, Som-

17. American Psychiatric Association.

Bakare M O. Attention deficit

merfelt K, Tylleskar T, Elgen I.

Diagnostic and Statistical Manual

hyperactivity symptoms and disor-

Coexisting symptoms and risk

of Mental Disorders.5th ed. Wash-

der (ADHD) among African chil-

factors among African school chil-

ington DC. American Psychiatric

dren: a review of epidemiology

dren with hyperactivity-inattention

Association; 2013.

and comorbidities. Afr J Psychia-

symptoms in Kinshasa, Congo.

18. Remschmidt H, Belfe M L., Good-

try 2012; 15:358-361.

Eur Child Adolesc Psychiatry

year I. Facilitating pathways care,

2006; 15(5): 292 – 299.

treatment and prevention in child

and adolescent mental health.2004

Berlin , Springer- Verla; 2004: 6.

334

19. DuPaul G J, Power T J, Anan-

22. Abikwi M I. Attention deficit

25. Biederman J, Faraone SV, Mick E,

stopoulos A D, Reid R. ADHD

hyperactivity disorder intervention:

Williamson S, Wilens TE, Spencer

Rating Scale IV: checklist, norms

strategies & counseling tips for

TJ, Weber W, Jetton J, Kraus I,

and clinical interpretation. New

primary school teachers. Edo J

Pert J, Zallen B. Clinical corre-

York: Guildford Press; 1998: 24.

Counseling 2009; 2(2):214-227.

lates of ADHD in females: find-

20. Bos Candace S, Maria L,

23. Gaub M, Carlson CL. Gender

ings from a large group of girls

Nahmias and Magda A.

differences in ADHD: a meta-

ascertained from pediatric and

Urban . Targeting Home-

analysis and critical review. J Am

psychiatric referral sources. J Am

School

Collaboration for

Acad Child Adolesc Psychiatry

Students with ADHD. Teaching

1997; 36(8):1036-1045.

1999: 38(8):966-975.

Exceptional Children 1999; 31: 4-

24. Gershon J. A meta-analytic review

11.

of gender difference in ADHD. J

21. Johnson, Lisa and Sarah Safranak

Attention Disorders 2002; 5

(2005). What is the most effective

(3):143-154.

treatment for ADHD in chil-

dren? J Family Practice, 2005: 1

-4.