Prithiviraj Bahadursingh1, Sitara Bachan1, Ria Rampaul1, Ambika Samsundar1, Gibran Ali1, Melissa Rooplal1
1 South-West Regional Health Authority (SWRHA)
Dr Prithiviraj Bahadursingh
South-West Regional Health Authority
Trinidad and Tobago
Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.
©2021 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association.
To describe co-morbidities that may impact the mental health of children diagnosed with ADHD in the community paediatric clinics, of the South-West Regional Health Authority (SWRHA), Trinidad.
Children with ADHD, followed up within the community paediatric clinics between January 2017 and February 2018 were identified. Case notes for each of these patients were retrieved; a performa was designed to collect specific information regarding ADHD and its co-morbidities. The data were analysed using Microsoft Excel.
One thousand and eighty seven patients (1087) were seen of which 130 (11.9%) patients were diagnosed with ADHD. Of the children with ADHD, 75.3% were male, 7.6% were preterm and 49% had learning difficulty. Thirty eight percent (38%) had Autism Spectrum Disorder (ASD); of these patients with ASD, 24% were high functioning ASD. Forty three percent (43%) were using methylphenidate (Concerta).
Of the 130 patients, 100 had Vanderbilt ADHD feedback forms (teacher and parent). Based on the teachers’ feedback forms, 38% had peer relationship problems, 54% reading difficulty, 59% writing difficulty and 42% difficulty in mathematics. Fifty percent (50%) of ADHD patients were referred to student support services but only 14.6% had a teacher’s aide.
Parent feedback forms indicated that 26% of children had anger problems and 13% depressive symptoms. Conduct disorder symptoms were reported in 9% and oppositional defiant disorder (ODD) symptoms in 41%. Teachers reported ODD symptoms in 28% of ADHD patients. 16% were in fights.
This descriptive study shows that children with ADHD have significant co-morbidities which can affect mental health. A prevalence study regarding ADHD is required in Trinidad and Tobago. There is need for further research regarding multidisciplinary support services needed for children with ADHD.
According to the Centers for Disease Control and Prevention (CDC), ADHD is one of the most common neurodevelopmental disorders with an estimated prevalence of 9.4%; 64% of children with ADHD also had another mental, emotional or behavioral disorder. 1 Thomas et al 2015, in their meta-analysis of 175 research studies worldwide showed an ADHD prevalence of 7.2%. 2 According to the European ADORE (Attention-Deficit Hyperactivity Disorder Observational Research in Europe) study, results found substantial ‘co-existing psychiatric disorders’, the most common being oppositional defiant disorder (67%) and conduct disorder (46%).3
Locally, there is limited data regarding ADHD and its mental health co-morbidities. A global student health survey in Trinidad in 2007 showed 39.8% of children being physically attacked, 20.8% being bullied and 16.5% belonging to violent groups. 4 It is not clear how many of these children may have ADHD. In our clinics, we have seen an increase in referrals for ADHD but the numbers diagnosed may be below the expected numbers based on international statistics.
In this study, we sought to describe the co-morbidities that may impact the mental health of children diagnosed with ADHD in our clinics.
Study Setting: Patients with ADHD followed up in the community paediatric clinics in the South-West Regional Health Authority (SWRHA) during the time period of January 2017 to January 2018 were selected for this study. There are five (5) community paediatric clinics at the SWRHA located at the Area Hospital Point-Fortin, Siparia District Health Facility, Princes Town District Health Facility, Pleasantville Health Centre and the Couva District Health Facility. There was one (1) lead consultant for these clinics who is a subspecialist in Community Child Health.
Study Design: This study was a retrospective observational study. Patients were identified from an existing community paediatric clinics patient database. This database is on Microsoft Excel and contains demographic and morbidity data for patients attending the clinics.
Data Collection: Case notes were reviewed. A performa was designed to record data regarding ADHD and its co-morbidities. The following information was recorded where available from the case notes: demographic data, medical and birth history, dietary history, co-morbidities including autism spectrum disorder, learning difficulty, obesity and underweight, referral to student support services, teacher aide support, peer support, psych-educational assessments completed, access to occupational therapy and cognitive behavior therapy as well as the use of medications for ADHD. Obesity and underweight were assessed using the World Health Organization (WHO) growth charts. Eating problems were noted based on the dietary history recorded in the case notes.
Data from the Vanderbilt ADHD feedback forms were also recorded into the performa. The Vanderbilt ADHD feedback forms are generally utilised to assess patients for possible ADHD. The questionnaires are based on the DSM V criteria for ADHD and are filled out by teachers and parents. The symptoms are scored ranging from no symptoms to symptoms occurring very often. The questionnaires also capture information on academic progress, oppositional defiant disorder, conduct disorder and anxiety symptoms.
Data analysis: The data were entered into Microsoft Excel and then analysed using Microsoft Excel. A descriptive analysis was then carried out.
A total of 1087 patients were seen in in the outpatient clinics between January 2017 and January 2018. Of these 1087 patients, 130 (11.9%) were diagnosed with ADHD. Ninety eight (98) patients of the 130 (75.3%) were male.
Of the 130 patients, 10 (7.6%) were born prematurely and 12 (9.2%) had a history of low birth weight (9.2%).
Fifteen percent (15%) were obese or overweight, 28% were ‘picky’ eaters based on dietary history and 13% were underweight. Thirty eight percent (38%) were on the autism spectrum (ASD) while 24% of these children on the autism spectrum were high functioning ASD. Learning difficulty was present in 49% of patients with ADHD.
Drug treatment with methylphenidate was utilised in 43% of patients with ADHD.
Vanderbilt Parent and Teacher Feedback Forms
Vanderbilt feedback forms from both parents and teachers were available for 100 out of the 130 patients. Based on the teacher feedback forms, 54% demonstrated reading difficulty, 59% writing difficulty and 42% difficulty with mathematics.
Thirty eight percent (38%) had peer relationship problems with teachers, giving a history of fighting in 16% of children and bullying in 17% of patients. Parents also gave a history of depressive symptoms in 13%, anger in 26% and conduct problems in 9% of children. Oppositional defiant disorder (ODD) features were reported by parents in 41% of cases but teachers reported features in 28% of cases. Thirteen percent (13%) of patients destroyed property according to parents’ response.
Figure 1. Data from the Vanderbilt ADHD feedback forms showing behavioural concerns.
Fifty percent (50%) of children were referred to the student support services for additional support inclusive of a teacher’s aide. Although 50% were referred, only 14.6% had received a teacher’s aide at the time of the study. Information regarding children who had psych-educational assessments to assess their academic abilities was not retrievable from the case notes. Information regarding peer mediated instruction and intervention was not retrievable from the case notes.
Information regarding children who accessed occupational therapy or cognitive behavior therapy was not retrievable from the case notes.
The 5-19 age group in Trinidad and Tobago was 283,656 based on Central Statistical Office (CSO) data for 2017. 5 Using an approximate population for the SWRHA of 600,000, the 5-19 age group within the SWRHA would be approximately, 130,000 indicating that there may be approximately 7500 children with ADHD based on a worldwide prevalence of 7.2%.2 Ninety percent (90%) of the referrals to our service have developmental concerns and in our study, 130 children (11.9%) seen had ADHD. 6 It is likely that ADHD is underdiagnosed in our population and a prevalence study would be required.
According to Vander Pleog Booth et al 2016, ADHD is the most common sequela of prematurity/very low birthweight for school-age children, with a prevalence rate of 11.5% to 31%.7 In our study 7.6% had a history of prematurity and 9.2% had a low birth weight. A study of ADHD prevalence among babies born premature or with low birth weight is needed in our population.
Cortese et al 2016 in their meta-analysis and systematic review regarding the association between ADHD and obesity found that the pooled prevalence of obesity was increased by about 70% in adults with ADHD and 40% in children with ADHD compared with subjects without ADHD.8 Our study found that 15% of children were obese or overweight. Further study would be needed to compare our ADHD population with the non-ADHD population in terms of obesity.
In a study done by Wijetunge et al in Sri Lanka 2015, of 200 children with ADHD, 69.5% had one or more neuropsychiatric co-morbidities. Of these, 54% had a single co-morbidity, whereas, 15% had two co-morbidities. 9 In addition to mental health co-morbidities, many children with ADHD also have a specific learning disorder. 10
Forty nine percent (49%) of the children had a learning difficulty and more than 50% had problems with reading and writing. In our context, access to full psych-educational assessments is limited. There is need for greater access to formal psych-educational assessments through the education system to diagnose specific learning disabilities. Only 14% of children had received teacher aide support. According to the CDC, a survey from 2014 showed that 9 out 10 children with ADHD had received school support. 1 There is need for greater investment in support for children with ADHD in the school setting.
According to the CDC, a national 2016 parent survey showed that 6 in 10 children with ADHD had at least one other mental, emotional, or behavioral disorder. 1 In our study, we used the Vanderbilt ADHD Diagnostic Teacher and Parent Rating Scale to screen for mental health co-morbidities. The mental health co-morbidities that were screened for included Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) as well as symptoms of anxiety and depression. Symptoms of ODD were present in 41% of the children in our study based on parent feedback. Conduct disorder symptoms were reported in 9% of our children with ADHD. Symptoms of depression were reported by parents in 13% of the children with ADHD in our study. Cognitive behavior therapy (CBT) is indicated for many of these children. According to a Cochrane review, CBT along with pharmacotherapy improved global functioning. 11 Forty three percent (43%) of children in our study were receiving pharmacotherapy. In our context, children are referred to the child psychiatry service which is currently under-resourced and children may not receive regular CBT as required. Further improvement in provisions for CBT at the child psychiatry services is required.
Problems with peer relationships were another domain that was screened for in our study. We found that 38% of the children had peer relationship problems. Thirty eight (38%) were also on the Autism spectrum. Children with ASD have difficulties with peer relationships. There is need for greater provisions for social skills supports in our context as well as peer mediated intervention and instruction.
Based on the review of case notes, information regarding children who had accessed occupational therapy (OT) was not obtained. Occupational therapy is a modality of therapy useful in children with ADHD and is not available through the SWRHA services. Chu et al 2007 found that children with ADHD showed improvement in behaviour after OT intervention. 12 Establishing OT within the public service is recommended.
This study was an observational study and a descriptive analysis was carried out. A control group was not utilised for this study. The sample size was small compared to the numbers expected based on international prevalence data. An analysis of the effect of co-morbidities and gender on ADHD symptoms was not carried out. It was a case notes review and information on some aspects of the multidisciplinary services was not available. A prospective study would be useful in our context.
This descriptive study shows that children with ADHD have significant co-morbidities which can affect mental health. ADHD may be underdiagnosed in our population. A local prevalence study regarding ADHD and its comorbidities including obesity is required. There is need for further research regarding the adequacy and availability of multidisciplinary support services including Cognitive behavior therapy (CBT), Occupational therapy (OT), teacher aide support and peer mediated instruction and intervention.
Ethical Approval statement: Ethical approval was granted by the South-West Regional Health Authority (SWRHA) Ethics Committee.
Conflicts of Interest statement: None declared
Informed Consent statement: Not Applicable
Funding statement: None
Prithiviraj Bahadursingh: Data collection, data analysis and write up.
Sitara Bachan: Data collection, data analysis and write up.
Ambika Samsundar: Data collection, data analysis and write up.
Ria Rampaul : Data collection, data analysis and write up.
Melissa Rooplal: Data analysis and write up.
Gibran Ali: Data collection and data analysis.
- Data and Statistics about ADHD CDC [Internet]. Centers for Disease Control and Prevention. 2020 [cited 25 March 2020]. Available from: https://www.cdc.gov/ncbddd/adhd/data.html
- 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(4):e994-e1001.
- Steinhausen H, Nøvik T, Baldursson G, Curatolo P, Lorenzo M, Rodrigues Pereira R et al. Co-existing psychiatric problems in ADHD in the ADORE cohort. European Child & Adolescent Psychiatry. 2006;15(S1):i25-i29.
- GLOBAL SCHOOL-BASED STUDENT HEALTH SURVEY (GSHS ) 2007 Trinidad and Tobago Report [Internet]. Who.int. 2020 [cited 25 March 2020]. Available from: https://www.who.int/ncds/surveillance/gshs/Tobago_GSHS_Report_2007.pdf valid link
- Statistics P. Population [Internet]. Central Statistical Office. 2020 [cited 25 March 2020]. Available from: https://cso.gov.tt/subjects/population-and-vital-statistics/population/ valid link
- Bahadursingh P. Community paediatrics SWRHA annual report 2017. 2017.
- Vander Ploeg Booth K. Attention-Deficit/Hyperactivity Disorder (ADHD) in Children Born Preterm and With Poor Fetal Growth. NeoReviews. 2016;17(4):e213-e219.
- Cortese S, Moreira-Maia C, St. Fleur D, Morcillo-Peñalver C, Rohde L, Faraone S. Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis. American Journal of Psychiatry. 2016;173(1):34-43.
- Wijetunge G, Dayasena J, Kulathilake I, Ratnathilake P, Namasivayam Y. Prevalence of comorbidities in children with attention-deficit and hyperactivity disorder at Lady Ridgeway Hospital for Children, Sri Lanka. Sri Lanka Journal of Child Health. 2015;44(2):77-81.
- Masi L. ADHD and Comorbid Disorders in Childhood Psychiatric Problems, Medical Problems, Learning Disorders and Developmental Coordination Disorder. Clinical Psychiatry. 2015;1(1):1-5.
- Lopez P, Torrente F, Ciapponi A, Lischinsky A, Cetkovich-Bakmas M, Rojas J et al. Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews. 2013.
- Chu S, Reynolds F. Occupational Therapy for Children with Attention Deficit Hyperactivity Disorder (ADHD), Part 2: A Multicentre Evaluation of an Assessment and Treatment Package. British Journal of Occupational Therapy. 2007;70(10):439-448.