Attention Deficit Hyperactivity Symptoms and Disorder Among African Children

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Attention deficit hyperactivity

symptoms and disorder (ADHD)

among A frican ch ildren: a review of

epidemiology and co-morbidit ies

IVIO Bakare

Child and Adolescent Unit, Federal Neuro-Psychiatric Hospital, New Haven, Enugu, Enugu State, Nigeria

Abstract

Object ive

To review literature from Africa on the epide miolo gy of

DHD

as well attention deficit hyperactivity sym ptom s

associated co-morbid conditions among African children. Method literature search was done through Pubmed/MEDLINE

Goo gle Scholar using then following terms, attention deficit , hyperactivity disorders , epidemiolog y , co-mo rbid conditio

Africa . Nine stud ies m et the inclusion criteria with four stu dies co ming from South Africa, two each from Democratic Repu

of Gongo and Nigeria respectively and one from Ethiopia.

Results

The prev alence of ADHD varie d with rates of betwe en 5

and 8.7%, amongst school children, 1.5% among st children rom he general population between 45.5% to 100.0% among st spe

populations of children with poss ible organ ic brain pathology Gommon as sociated co-mo rbid con ditions were opp ositional de

disorder, conduct disorder as well as anxiety/depressive symptoms. Conclus ion Pub lished data from'Africa is limited.

effective healthc are policy further studies are ne ed ed to define the magn itude an d burd en of ADHD and other childh ood neu

developmental disorders in Africa.

Keywords

Attention deficit; Hyperactivity; Symptoms; Disorders; Africa

Rece ived

20/06/2011

Accepted 25/09/2011

doi http://dx.doi.org/10.4314/ajpsyvl5i5.45

Introduction

A debate exists as to whether attention deficit hyperactivity

diso rder (ADHD) might b e a cultural construct.'-= The opinion

that geog raphical location may have some influence on

epid emio logy of ADHD and Attention Deficit Hyperactivity

Symptoms remains''^, despite a few stu dies h aving

concluded, with some level of caution however, that culture

and geographical location may have little or no influence on

the epidemiology of ADHD world-wide.^''

In their systematic review of literature on the world-wide

prev alen ce of ADHD, Polanczyk et al̂ found a pre valen ce of

about five percent. However, they cautioned against

generalization of their findings, especially in geographical

regions of Africa and Middle East be cau se th ese regions

contributed very few studies to their meta-analysis.^

Though controversy persists about the influence of cu

and geog raphical locations on the epidem iology of ADHD

there has been general agreement amongst studies that

method of assessment, diagnostic criteria employed, sou

of information and inclusion of imp airme nts in functioning

operational definition criteria greatly influence the preva

rates documented in the literatu re. ' '

WhOe chüdhoo d DHD has bee n extensively rese arc

in Europe and North America, very few studies are availa

in the African sub-region. Since the publication on world-

prevalence of

DHD

in 2007^, a num ber of studie s h ad



Afr

Psych ia try 2012 ; 15 :358-361

There ha s be en no prior review of the prevalence of

ADHD symptoms docum ented

in

different

of sub-S aharan Africa. The current content

a

review of past epidemiological

ies on ADHD, Attention Deficit Hyperactivity sym ptom s

ions documented sub-

ew com prised a literature search of the following

- Pubmed/MEDLINE and Google Scholar, using

foüowing term s; attention deficit , hyperactivity

rs , epidemiolog y , co-mo rbid conditions ,

to

epidem iolog y of ADHD,

cted literatures which were relevant to Africa

in

area of

iology of ADHD and

ADHD

symptom s were also

AU

studies add ressing epidem iology of ADHD,

HD symptom s and co-morbidities in Africa and carrie d

he review. The last up date d search w as unde rtaken in

Ethical clearance for this study was obtained from the

itutional Review Board of Federal Neu ropsy chiatrie

9)

studie s relevant

to

aspects of

ADHD an d ADHD

ptom s in Africa.'''^ Whu e four of the stud ies w ere from

ricaä.'o.iz.is^ two st ud ies ea ch we re from N ig er ia' '

ocratic Republic

of

Congo^'''' respectively, and only

iology of ADHD among p opulation

of

school

dren in Africa'''2.i3,i4 on e study amo ng p opulation of

in the gen eral community.'^ Three stu dies^' '

addressed epidemiology of ADHD symptoms among

special populations

of

chü dre n with HIV infection,

tuberc ulosis meningitis, and intellectual disability in Africa,

whue one study dealt solely with co-morbid conditions.^

The detaüs of the reviewed literature

are

shown in Table

I.

iscussion

Epidemiology of ttention Deficit Hyperactivity Disorders

ADHD) among populations of school children in frica

The prevalence of ADHD amo ng school chü dren accordin g

to studies cond ucted in Africa ra nge s betw een 5.4% and

3 7o „ 7,12.13.14 The studies coming firom South Africa

documented a prevalence of abou t five percen t, which

concurred with the finding

of

a prevalence

of

abo ut five

percen t in the meta-analysis study of word-wide prevalence

of ADHD by Polanczyk et

al.^

The only epidemiolog ical

study among school chüdren co ming from the Dem ocratic

Republic of Congo docum ented a prevalence of 6.0%, wh ue

the only epidemiological study com ing from N igeria amo ng

school chüdren revealed

a

prevalence

of

8.7%.

There were m tütiple sourc es of information for making

the diagnosis of ADHD in the se studie s with all of the

studies making use of information from b oth the par ents

and the teachers albeit employing different diagnostic

instruments.'•'^•'^•'''

Epidemiology of ADHD among children n the general

population sample

The rate of primary school enrolment in African countries

had been noted to range from about thirty to ninety five

percent, with much lower rates in sub-Saharan African

countries.'8 Therefore the prev alenc e stu dies of ADHD

carrie d out among sub-Saharan African chü dren in primary

schools'''^''^''^ might not be representative of the actual

prevalence in the general population. Unfortunately, only

one study had looked at prevalence of ADHD am ong

chüdren selected from

a

general population sample

in

Africa.'5 Ashenafi

et

al'^ found the prevalence of ADHD

among chüdren from the general population in a district in

i

Country

of

Origin

and

Pop ulation

of

Children Studied

in the

Reviewed Literature

uthor s

et

al (2005)

et

al (2006)

Famuyiwa (2007)

et

al (2001)

ountries

o

Origin

South A frica

South A frica

Democratic R epublic

of

Congo

Democratic R epublic

of

Congo

Nigeria

Ethiopia

Population

o

hiidren Studied

School Children

School Children

School Children

School Children

School C hildren

Children from the General Population



Ethiopia to be 1.5%. The pre vale nce of 1.5% ih this study 's

is by far lower than the range of 5.4% to 8.7% documented

in the studies conducted among primary school children in

South Africa, Nige ria an d Dem ocratic Repu blic of

The reasons for the apparent disparity in prevalence

betw een the community and school studies are not quite

de ar . There is however a possibility that sym ptoms of

ADHD, especially in-attentive sub-type are made more

noticeable and apparent by the school environment

compared to the home or community environment where

high levels of concentration might not be required in normal

routine tasks. Another possibility is the difference in

diagnostic instruments employed in assessment before

arriving at a d iagn osis of ADHD. However, this possibility is

more remote because the diagnostic instruments employed

in all the stud ies'''2''3'i'''5 factored in diagno stic criteria

specifled in the World Health Organization (WHC)

International Classiñcation of Dise ases, Tenth Edition (ICD-

10) and Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition (DSM-IV).'«

Epidem iology of Attention Deficit Hypera ctivity Symp toms

in special pop ulation of children with possible organ ic

brain pathology in frica

• Three stud ies a dd resse d epidemio logy of Attention Deflcit

Hyperactivity Symptoms in special population of children.'-

Zeeg ers et aP asse ssed the epidemiolog y of ADHD

amo ng HIV infected South African ch ildren. They found a

com bined prevalence of ADHD to be 88% in the stud ied

population, with inattentive type accounting for 26%,

hyperactive type, 38% and com bined type, 24%.̂ In an other

study Wait et al'° explored the association betw een

tuber culos is men ingitis and Attention Deficit Hyperactivity

Symptoms. They found that one h und red p ercent (100%) of

children that had just recovered from tuberculosis

mening itis had Attention Deflcit Hyperactivity Sym ptoms.

Based on this finding, they speculated that ADHD may be a

long term complication of tubercu losis mening itis.' Both

studies^'' further reinforce the possibility of organic brain

conditions as aetiological factors in ADHD amon g African

children. Bakare et al looked at prob lem behaviou r amon g

children with intellectual disability The study found a

prevalen ce of 45.5 % hyperactivity sym ptoms amon g

chüdren with intellectual disability '

One of the pr op os ed aetiological factors of ADHD is

brain damage resulting from circulatory toxic, metabolic,

mechanical or physical insults.'^ The high prevalence of

Attention Deflcit Hyperactivity Sym ptoms rang ing from

about forty five to one hundred percents as documented by

the aforementioned studies^ '' supp orts the notion that

possib le brain dam age is an important aetiological

explanation for ADHD am on g African children.s.'o. The

prevalence distribution of ADHD/ADHD Symptoms in

different population of children in Africa is shown in Table

Epidemiology of ADHD gender differences and co-

morbidities in frica

Regarding g ender, all the studies on epidem iology of

ADHD among African children reviewed agr eed on a hig

prevalence of ADHD or Hyperactivity symptoms among

boys compared to girls.'''9''0' ''2.'3.'4's

The most commonly reported co-morbid conditions

associated with ADHD among African children were

Oppositional Deflant Disorder (ODD) and Conduct

Disorder.•'•8.9 i.'s Anxiety and depressive symptoms may

also co-exist with ADHD among African C hildren .' How

frequently these co-morbid conditions co-exist with ADH

varied according to the population samp le of children

studied.

Limitations

It is important to emp has ize that the ex isting literature in

fleld of ADHD from A frica is relatively sp ars e w hich limits

the ability to realistically generalize the findings of this

review as the prevalent trend of ADHD and attention deflc

hyperactivity symptoms among African children. A furthe

limitation may be that the search approach did not identif

aU

relevant stu dies. Notw ithstanding th ese limitations, it i

imperative to examine the existing data to determ ine the

know ledge g aps related to the epidem iology of ADHD an

attention deflcit hyperactivity symptoms among African

chüd ren. It is bejieve d that the findings of this review will

guide future epidemiological studies of ADHD and

subse quen t p olicy making in Africa.

Conclusion

The prevalence of ADHD in Africa based on studies comi

from the continent range s betw een 5.4% and 8.7% amo ng

populations of school children''^''^^'i with the prevalence

bein g much lower amon g a population of chüdren from th

gene ral community where a prevalence of 1.5% was

documented. '5

In addition, studies from Africa affirmed that Attention

Deflcit Hyperactivity symptoms do complicate various

conditions, characterized by p ossible organic brain

pathology, in chüdren.^s.io^o The n ee d to prevent the se

conditions, which have the potential for damaging effects

the develop ing brain, amon g African chüdren is thus

imperative.

Tabie ii: Prevaience of AD HD ADHD Sym ptoms amongst different popuiations of African chüdren

Population o Children

Prevalence o ADHD ADHD Symptoms



Afr Psychie

Limited research studies are avaüable from the continent

essing the epidemiology of ADHD

and

other chüdhood

Such studies

are

essential

on intervention and healthcare

is a

further reflection

of

less attention

of chüdhood neuro-developmental disorders

If adequate health service planning is to be put in place

the African continent further studies are required to

and

rden of ADHD and other chüdhood neuro-developmental

for

providing list of

in their study. The author is also

to Dr. Adewuya

for

his assistance

in

providing

a

of their study

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Attention Deficit Hyperactivity Symptoms and Disorder Among African Children