Prevalence of ADHD in Qatari School-Age Children

Abstract

Objective: The purpose of this quantitative survey study is to provide current accurate estimates of the number of students with ADHD in Qatar Independent and English Medium Private Schools, so that adequate support will be available to assist in the educational growth and development of these students. Method: This cross-sectional descriptive study of teacher observational ratings used a standardized rating scale. Teachers completed the SNAP-IV. Rating Scales for more than 5,000 students from Qatar Independent Schools and private English Medium Schools between November 2011 and November 2012 in Qatar Grades 1 through 12. Results: Results align with and extend the previous study of ADHD in Qatar and the current worldwide prevalence. Conclusion: Enhanced analyses were conducted to identify differences between age groups, genders, and between Private and Independent Schools. Implications for teachers, administrators, and medical personnel are discussed.

Keywords

prevalence children youth academic performance peer relationships

Prevalence of ADHD in Qatari Students

ADHD is the most common neurobiological disorder of childhood affecting between 9.5% and 16% of all school-age children (Center for Disease Control, 2010; Jensen et al., 1999; Rowland et al., 2001). The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) describes ADHD as typified by pervasive and impairing symptoms of inattention, impulsivity, and hyperactivity.

ADHD has been associated with a broad range of negative outcomes for children including academic underachievement, social difficulties, and financial and mental burden to families and society and thus can be characterized as a major public health problem (Dulcan, 1997; Swanson et al., 1998). ADHD is often seen as more of a problem for the school-age child with ADHD, affecting their academic performance and self-esteem and interfering with their academic and social success in school (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Daley & Birchwood, 2010; Danckaerts et al., 2010; Hakkaart-van Roijen et al., 2007; Kessler et al., 2005; Lesesne, Abramowitz, Perou, & Brann, 2000; Loe & Feldman, 2007; Polanczyk, Silva de Lima, Horta, Biederman, & Rhode, 2007). Untreated ADHD is a principal cause of lack of success for many adults (Brook, Brook, Zhang, & Koppel, 2010; McCabe, Knight, Teter, & Wechsler, 2005). Research has found that teenagers and young adults with untreated ADHD have lower probability of attending college or university; they experience negative encounters with the law more frequently, experience more divorce or difficulty with establishing and maintaining positive relationships, and underachieve in the workplace. The social and emotional impairments involved in ADHD affect the quality of life for these people and their families (Anastopoulos et al., 1992; Dosreis et al., 2003; Hakkaart-van Roijen et al., 2007; Hamed, Taha, Sabra, & Bella, 2008; Loe & Feldman, 2007; Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007; Podolski & Nigg, 2001; Wehmeier, Schacht, & Barkley, 2010). A meta-analysis of studies of the prevalence of ADHD worldwide in school-age children showed that prevalence ranged from 2% to 20%. Researchers were not able to attribute the differences to geographic location but stated that the data suggested study methodology as the only correlate of this range in prevalence (Polanczyk et al., 2007). In a meta-analysis of ADHD studies in the Arab region, findings were similar to Polanczyk et al. (2007) in that the prevalence varied more with the study methodology than with a particular area (Farah et al., 2009). Farah et al. (2009) stated that more research is needed to assess national prevalence of ADHD in the Arab region. For example, the 2006 estimate of ADHD prevalence in Qatar suggested up to 19% of children in Qatar ages 6 to 12 years in government schools have moderate to high levels of ADHD according to teacher rating on the 10-item Conners’ Classroom Rating Scale for ADHD symptoms (Bener, Al-Qahtani, & Abdelaal, 2006). This equates to more than 15,000 Qatari students who may or may not be receiving assistance with management of a potentially debilitating disorder that can limit a person’s success in life. In their study, Bener et al. (2006) suggested that the higher prevalence in Qatar than in other parts of the world is related to “biologic, culture and family factors” (p. 77). The meta-analysis of twin and adoption studies by Rhee and Waldman (2002) also established familial or biological links in ADHD. In their clinic-referred sample, 34% to 40% of the participants with ADHD reported a family history of ADHD compared with 8% of control participants.

Clinical procedures for ADHD identification are multifaceted and ecological. Often there are observations of the student in the classroom and possibly in the home by an independent observer, such as a school or educational psychologist. Parents and teachers complete a standardized checklist, usually derived from the DSM-IV-TR (APA, 2000). Standard procedures dictate that the parent and teacher checklists must correlate to demonstrate that the disorder is found in more than one situation (such as the school and the home) and not situation specific, which would lead one to believe that the situation may be the problem and not a disorder inherent in the child (Alloway, Gathercole, Holmes, Place, & Elliott, 2009; Pediatrics, 2000). Medical interviews and examinations are conducted and a trial of stimulant medication may be offered or a multidisciplinary team may meet to discuss other possible strategies. Follow-up checklists for parents and teachers are carried out to ensure that the child is responding, in the desired direction, to the strategies and or medication and that the correct dose is being administered. Without a diagnosis of ADHD, the child may not receive any interventions, continue to underperform academically and behaviorally at school, and cause family stress (Anastopoulos et al., 1992; Podolski & Nigg, 2001).

Purpose of This Study

Without current accurate information about the prevalence of ADHD in Qatari schools, adequate resourcing of schools and other systems within the country, to deal with this challenge, will not likely be provided. The purpose of this study is to provide current accurate estimates of the number of students with ADHD in Qatar Independent and Private Schools so that adequate support will be available to assist in their positive growth and development as young people and to bring awareness of the disorder’s prevalence to health services and educational institutions.

Method

Between November 2011 and November 2012, a cross-sectional descriptive study of teacher observational ratings using a standardized rating scale, the SNAP-IV, was completed in Qatar Independent and Private Schools Grades 1 through 12. The SNAP was developed by Swanson (Swanson, Baler, & Volkow, 2011) in 1983 and updated with each updating of the DSM to the DSM-IV thus the current SNAP-IV (Swanson, 1995). Teachers completed the SNAP-IV Rating Scale and six questions regarding academic and social functioning for each student in their classroom. Demographic data were collected for each teacher and results were analyzed for frequencies and percentages.

Participating Schools

Stratified random sampling of all the Independent and Private Schools in Greater Doha area was used. Schools were stratified according to district and male/female schools, where applicable, with a target of 5,000 completed rating scales. Schools were randomly selected and an invitation was sent to participate in this study, invitations were followed up with telephone calls to the school head who either consented or declined to participate in the research. One school declined to participate and another school was selected from the remaining schools to replace it. All students in each school that were present on the day of the survey were included. Ten Independent Schools and two Private Schools consented to participate. To ensure teachers had adequate time to “get to know their class,” surveys were distributed at least 2 months after the beginning of the 2011-2012 school year. A time was arranged to provide the school with a workshop on ADHD, to explain the research procedures and to secure teacher consent to participate. Teachers were asked to complete the SNAP-IV short version of 18 questions and 6 additional questions regarding academic and social performance for each student in one of their predetermined classroom, determined by the school head or designate where teachers taught more than one group of students. At the end of the workshop, teachers in Independent Schools were provided Arabic translation of the SNAP-IV forms for each student and forms were collected 1 week later. Teachers in Private Schools received the English copy of the SNAP-IV. Demographic information of teachers was also collected in either Arabic or English.

Qatar Independent Schools are structured in three groups: primary, Grades 1-6; preparatory, Grades 7-9; secondary, Grades 10-12; and are also divided by gender. Each school is independently owned yet the Supreme Education Council oversees the activities of the school and sets standards for activities in the school. At least one Independent School from each level and gender participated in this study. In addition, teachers from two private English Medium Schools that cater almost exclusively to Qatari students were asked to participate and total 5,114 students were rated. Due to missing information, the total number of students analyzed were 4,489 of the 5,114 forms. As shown in Table 1, the population was divided into age groups to more closely match the previous study and facilitate comparisons. A total of 2,294 male students and 2,195 female students were rated. There were 862 boys 6 to 9 years of age and 567 girls in the same age group. The 10- to 12-year-old students composed of 641 boys and 543 girls with the remaining student 13 to 19 years of age composing 791 males and 1,085 females. In Private Schools, there were 569 boys and 465 girls, and in Independent Schools, there were 1,725 boys and 1,730 girls rated by teachers included in the data analysis.

Table 1.

Characteristics of Student Populations by Gender.

Type of school	Years of age	Male (n = 2,294)	%	Female (n = 2,195)	%
All schools	6-9	862	60.3	567	39.7
	10-12	641	54.1	543	45.9
	13-19	791	41.9	1,085	57.5
Private	Total	569	55.0	465	45.0
Independent	Total	1,725	49.9	1,730	50.1
	Total	2,294	51.1	2,195	48.9

Participating Teachers

Most teachers in Independent Schools are hired from surrounding Arab countries such as Jordan and Egypt. Approximately 24% are from Qatar and 70% from other Arab countries (Supreme Education Council, 2011). Private Schools are staffed by about 50% Western teachers. In this study, of the 256 teachers who completed the demographic information, more than 22% were Egyptian, 21% Jordanian, 14% Qatari, 6% Syrian, and other nations around the globe being represented with between 1 and 15 teachers for each country. Private Schools’ teachers who completed the rating forms included teachers from the United Kingdom, South Africa, Canada, Australia, New Zealand, and the United States.

Instrument

Since the early 1970s, rating scales have become the standard measure for the assessment of ADHD in students and have been found to be as reliable as behavioral screening tests (Barkley, 1981). The SNAP-IV Rating Scale for ADHD (Swanson, 1995) was administered in this study because it has been used in many studies of ADHD including treatment studies (Agency for Health Care Policy and Research, 2009). The SNAP-IV Rating Scale was chosen in this study for its utility, ease of completion, and for its reliability and validity with all populations. This rating scale is a revision of the original SNAP questionnaire (Swanson, 1995) and updated to the SNAP-IV to correspond to the updating of the DSM-IV (APA, 1994) and revised DSM-IV-TR (APA, 2000) constructs for ADHD. The DSM-IV criteria for ADHD include both inattention and hyperactive/impulsive behaviors. SNAP-IV questions 1 to 9 relate to inattention and questions 10 to 18 to hyperactivity/impulsivity and are based on a 0 to 3 rating scale not unlike other standardized ratings scales for ADHD with 0 = Not at All; 1 = Just a Little; 2 = Quite a Bit; 3 = Very Much. Each of the areas of Inattention and Hyperactivity/Impulsivity is averaged along with the Total for a score of Combined ADHD. Both teacher and parent scores are given separate cutoff points derived from scores above the 95th percentile based on the expected rate of ADHD in the population at the time the cutoffs were calculated. On the SNAP-IV, the teacher cutoff point for Inattention is 2.56, for Hyperactivity/Impulsivity 1.78, and total Combined ADHD score at 2.0. No difference is provided for age nor for gender differences. Today the prevalence is believed to be at or above 10% and thus the current cutoff may not be appropriate and may need to be greater to include more children; for this study, the original SNAP-IV cutoff of 5% was used. An investigation of the SNAP-IV for screening and diagnostic purposes by Bussing et al. (2008) found acceptable internal consistency and item selection. Furthermore, Bussing determined that it adequately discriminates children with varying levels of ADHD. Bussing’s study did not support the need for stratified age cutoff points nor the notion that as children mature their ADHD behaviors decrease.

Ethics

This study was reviewed and approved by both the Hamad Medical Corporation ethics committee and the Supreme Education Council Research office before it was undertaken. Furthermore, each school head was advised and agreed to participate in the study as were teachers who were the actual participants of the study. Teachers who completed the assessment instrument also signed a written permission to share results including demographic data. Students were not identified by name and only a student ID was placed on each checklist. Each school was advised to notify parents of the school’s participation in this study, so they could indicate if they did not wish their child’s rating to be included.

Results

Fully completed SNAP-IV Rating Scales were obtained for 4,489 students between the ages of 6 and 19: 51.1% were male and 48.9% female. Two distinct types of schools participated: Qatar Independent Schools and Private English Medium Schools both with the majority of students of Qatari descent. The Private School population comprised 1,034 students while 3,455 students attended Independent Schools. Results of the prevalence of ADHD symptoms were stratified by age groups of 6 to 9 years, 10 to 12 years, and those more than 12 years of age as shown in Table 2.

Table 2.

The Prevalence of ADHD Symptoms Among the Studied Participants by Age Group and Gender.

Variable	Attention deficit	Hyperactive	Combined but neither attention deficit nor hyperactive	Total ADHD	%	p
Age group (years)
6-9	53	104	6	164	11.56	<.0001
10-12	46	65	1	112	9.46
>12	39	57	1	97	5.14
	138 (3.1%)	227 (5.1%)	8 (0.004%)	373 (8.3%)
Gender
Male	99	170	7	270	11.77	<.0001
Female	39	57	1	97	4.42
Gender and age group
6-9 M	47	89	5	141	16.36	<.0001
6-9 F	6	16	1	23	4.13
10-12 M	32	46	1	79	12.32
10-12 F	14	19	0	33	6.08
>12 M	20	35	1	56	7.08
>12 F	19	22	0	41	3.78

Note. M = male; F = female.

The prevalence of symptoms of ADHD in Qatari students between the age of 6 and 19 varied greatly between age groups and genders. The data revealed that boys between the ages of 6 and 9 years demonstrated the greatest number of symptoms related to ADHD with 16.36% of them registering above the 5% cutoff for ADHD according to the SNAP-IV whereas only 4.13% of the girls in the same age group indicated ADHD symptoms. Of the boys between 10 and 12, 12.32% exhibited ADHD symptoms above the 5% cutoff point of the SNAP and 6.08% of the girls were found to have enough symptoms to be considered for clinical assessment of ADHD. Students 13 years and older or those in intermediate and secondary school exhibited fewer ADHD symptoms with males exhibiting 7.08% and females 3.78%. As per the data, males exhibited symptoms of ADHD almost three times as frequently as females, 11.77% to 4.42%, respectively. Overall, the average percentage of students age 6 to 19 exhibiting ADHD symptoms in Qatar schools amounted to 8.3%.

The average of all students’ academic performance revealed that 13.8% to 15.2% were having academic difficulty. The range for academic difficulty per teacher ratings was 40% to 44% for those students with clinical symptoms of ADHD.

Teachers rated the social interaction of the students with ADHD. Social difficulties were more frequently noted for the students who were rated high for ADHD. Approximately 7% of the general student population experienced social difficulty with peer relations whereas 37% of students rated with high ADHD exhibited difficulties with peer relations. Overall difficulties with learning for the students rated ADHD were more than 56% while the total for all students was 12%.

Further examination of data disclosed a disparity between Private and Independent School students with ADHD symptoms. Teachers in Private Schools rated almost twice the number of total students with ADHD compared with ratings from the teachers of the Independent Schools, 12.3% and 8.3%, respectively. Further break down by age was not provided due to the smaller number of Private School ratings in each category.

Discussion

The results of this study revealed that ADHD is a disorder frequently identified in Qatari school-age children according to the teacher ratings: yielding a total average percentage of students from Grades 1 through 12 at 8.3%. The results mirror results reported by Bener et al. (2006) who found an overall prevalence rate of 9.4% as rated by schoolteachers. The smaller difference may be explained by the fact that Bener’s study encompassed students from 6 to 12 years of age only. On examination of the current study for students’ age 6 to 12, the rate of ADHD was 10.6%. These percentages fall in the range of Farah et al.’s (2009) analysis of all studies published in the Arab region from 1966 through 2008. Data from other studies in this region have demonstrated rates of ADHD from 4.3% to more than 9% (Al-Sharbati, Zaidan, Dorvlo, & Al-Adawi, 2011; Hamed et al., 2008; Thabet, Ghamdi, Abdulla, Elhelou, & Vostanis, 2009). Most of these studies have used a similar local population often from two types of schools but have used the original Connors’ 10-item DSM-IV checklist, constructed in the 1970s. More recently, a 2009 study of the prevalence of ADHD in the UAE found only 4.1% as per parent report and 3.8% as per teacher ratings on the older Connors’ 10-item checklist (Eapen et al., 2009). In Oman, Al-Sharbati et al. (2011) found more than 15% of children being identified as high for ADHD. Thus Qatar prevalence does not seem to be out of line at 10.6% for the 6 to 12 years of age or 8.3% overall for the Arab region.

This study also found a difference in ADHD between genders as has been demonstrated by other researchers (Al-Sharbati et al., 2011; Bener et al., 2006; Farah et al., 2009). The difference between male and female prevalence of ADHD is a well-known fact demonstrated in almost every study of prevalence.

As in the Bener et al. (2006) study, the current study found that students who scored with more ADHD symptoms on the SNAP-IV also experienced more difficulty academically with reading, writing, mathematics, and social skills. Assisting students and teachers to bridge this academic gap would be beneficial for everyone. Students scoring in the clinical range of ADHD could experience more success academically and in social interactions with their peers.

Finally, it was found that Private Schoolteachers in Qatar identified significantly more students with ADHD than teachers from Qatar Independent Schools. Separating the two groups of teacher ratings, it was found that only 8.3% of students were identified from Independent Schools compared with the 12.3% of students from Private Schools that were identified with ADHD. The researchers suggest differences between students, teachers, and school format may account for this difference.

The differences seen between the teacher ratings of students in the Private Schools and those in the Independent Schools can be understood from several different perspectives. One perspective could be to think about the differences between the families and where they send their children for schooling, yet research does not support this theory. Analysis of several researchers suggest a greater number of students with ADHD come from homes with lower socio-economic status (SES), which doesn’t fit with the theory that those with lower SES, where there are a greater number of students with ADHD, send their children to Private Schools, thus the higher rate of ADHD symptoms (Froehlich et al., 2007; Stone, Brown, & Hinshaw, 2010).

Private Schools in this study are English Medium with teachers whose first language is English who seldom speak or understand Arabic, the language of the students. Thus, one could suppose that as English is a second language for these students, they are under more pressure to listen and pay attention than students working in their own language and to do so is difficult. Thus, more misbehavior or the teachers pick up quickly that they are not attending.

Another theory to explain this difference in percentage of ADHD is to examine the cultural difference in norms and mores for children between teachers who are from English speaking countries and those from Arabic speaking countries. There may be different expectations for student behavior in the two groups of teachers.

Teacher training and school structure could be another theory to explain the differences. Perhaps awareness of ADHD is different between the two types of schools. It was noted that the majority of the teachers in another study of Qatar Independent Schools illustrated that these teachers did not have basic knowledge about ADHD (Bradshaw & Kamal, 2013). Differences in teaching style and practice between the Private Schools and the Independent Schools and teachers participating in this study might also explain the differences. There could be a difference in the structure of teaching and education, in general, between the two different types of schools. In Private Schools, the English speaking teacher in Grades 1 through 6 spends more face to face time with each student than teachers in Independent Schools. Thus with this extra time to get to know and understand a student, they may be more cognizant of the symptoms listed on the rating scale. Each teacher in an Independent School spends considerably less face to face time with each class as the school day is divided by subject−teachers, even at the first-grade level. Whatever the differences, it is suggested that future researches examine these differences between schools and teachers so students can benefit from the best of both systems.

Limitations

Teacher surveys rely on the assurance that teachers can make the distinctions necessary in recognizing or noticing students that match the descriptors on the checklist, some may not be able to recognize the variances among their students, do not have the students long enough in each day or week or lack skills in classroom management that may skew results. Another study with the same teachers found that many teachers had misperceptions about ADHD as a disorder (Bradshaw & Kamal, 2013). Even though these teachers received a short workshop on ADHD awareness prior to completing the SNAP-IV, they were asked at the beginning of the workshop if they could describe a child with ADHD and if they had taught one such child. Many felt that they already knew which students had ADHD and stated so in the workshop saying they did not need to complete the SNAP-IV for each student, just the ones with ADHD. Thus, the researchers do not feel the workshop biased this study but further research into the effects of workshops prior to completing surveys would help to answer this question.

Teacher demographics could not be linked to student data sheets and the translation of the term “Attention Deficit Disorder” did not translate accurately into Arabic. Although teachers received a workshop on ADHD prior to completing the forms, this language translation barrier may still have affected the results. Follow-up research should link teacher experience, education, and attitudes toward ADHD with ratings for each student and statistical evaluations of the relationships between these teacher demographics and the rating of students would provide insight into the relationship between teacher education, age, and experience to the rating of students with possible ADHD.

Only a small percentage of possible schools in Qatar participated and although the total number of students evaluated is large, the number of schools is small in relation and thus results should be cautiously generalized to schools outside the greater Doha area. Another limitation is the lack of a broad representative sample of all private schools in Doha given that only two private schools participated in this study. Future research would be more relevant with a stratified sampling from many schools to increase the reliability of these results.

Although most studies only use one setting for administration of rating scales, the DSM-IV requires that the ADHD behaviors must be present in more than one setting. This study attempted to present parents with rating scales to complete, parents were very defensive, and either refused to complete the checklist or stated that “there is nothing wrong with my child” marking every item as “never,” and thus it was believed that the parent data collected were not reliable and thus not included.

Conclusion

The data from the present study has demonstrated that ADHD is a common challenge for students and their teachers in Qatar. Despite the important limitations, this study has implications for health services, the medical profession, parents, teachers, and schools who struggle on a daily basis to make the best decisions for their patients/students. This study offers further substantiation, with a larger and wider sample than previous work, that ADHD is affecting around 10% of the population in the 6- to 12-year-old group of students and needs support from all stakeholders. It points to the fact that these students with ADHD are experiencing social difficulties at a time when children need to have friends and the support of others to help them through school and life with a neurobiological disorder. Students with ADHD symptoms are also experiencing difficulties with learning at an age when learning should be fun and seamlessly part of their existence instead of a struggle in the best years of their life.

Footnotes

Acknowledgements

The authors thank Dr. Ann Nevin for her continued mentoring, excellent feedback, and wordsmith brilliance.

Authors’ Note

The study was endorsed by government and principals at participating schools. The funding organization played no role in the design and conduct of the study, in the collection, management, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Based on the report of research Grant NPRP No. 4-169-3-055 titled, “Prevalence and Management of Attention Deficit Hyperactivity Disorder Among Qatari Students.”

Author Biographies

Lori G. Bradshaw, PhD, has more than 10 years experience as assistant and associate professor in the area of Special Education-Mild and Moderate. She held a tenure track position at Arizona State University, lectured at Northern Arizona State University and held full time positions at universities in Mexico, Brunei, Bahrain, and now in Qatar. For the past 5 years she has consulted with schools, agencies, and families to assist with the inclusion of students in the most appropriate programs available and worked with children with attention deficits and their families on behaviour plans.

Madeeha Kamal, MBCHB, FAAP, FRCP(C), is a Senior Consultant Pediatrician at Hamad Medical Corporation in Qatar and also holds the position of Assistant Professor Weill Cornell Medical School-Qatar. Dr Kamal is Canadian trained and her focus is on children with attention difficulties.

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