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Original Research Article

A study to calculate Prevalence of Adult Attention Deficit

Disorder in medical & para-medical students of Central India
and its association with various risk factors

Goutam Pritesh1, Kaushal Rituja2, Goutam Mahima3

1
Assistant Professor, Department of Neuro Psychiatry, LNMC & RC, Bhopal.
2
Assistant Professor, Department of Community Medicine, LNMC & RC, Bhopal.
3
Tutor, Department of Community Medicine, LNMC & RC, Bhopal.
Corresponding author: Rituja Kaushal
Email – dr.rituja@gmail.com

ABSTRACT

Background: To resolve the mystery of Attention Deficit Hyperkinetic Disorder (ADHD) in adults and to
assess its prevalence & association with various risk factors.
Methodology: This cross sectional analytical study was carried out with specific inclusion & exclusion
criteria on different selected variables. This study was undertaken in the campus of R D Gardi Medical
College, Ujjain over medical & paramedical students. Chi square qualitative statistical analysis was done
to evaluate the association of risk factors with the outcome of disease.
Results: The prevalence of ADHD in the study group was found to be 15.9% (56 out of 353 patients).The
most common type of ADHD found in the study population was - Inattentive type (50%) – 28 out of 56,
followed by Hyperactive type (18%) – 10 out of 56, Combined type (32%) – 18 out of 56. Among the
diagnosed 56 Adult ADHD patients 59% were males and 41% were females. Level of education was found
to be a statistically significant factor in association with occurrence of ADHD in adulthood. Other factors
considered in study like age, gender, presence or absence of other co- morbid psychiatric disorders were
not found to be statistically significant in association with ADHD. Also variables of past history like rash
driving, road traffic accidents, frequent quarrels, substance abuse or learning difficulties in school were not
found to be significantly associated with adult ADHD in our study.
Conclusions: It was concluded that such studies should be undertaken frequently at different locations in
different time frames to tackle this devastating problem in early stages.

Keywords: Adult ADHD, Prevalence, Risk factors, medical students, paramedical students

(Paper received – 16th January 2018, Peer review completed – 10th February 2018)
(Accepted – 12th February 2018)

INTRODUCTION

Few researchers still point Attention Deficit Disorder (ADD) as a simple behavior disorder. Increasingly,
specialists are recognizing that it is a complex syndrome of impairments in development of the brain’s
cognitive management system, or executive functions. This disorder affects one’s ability to 1) Organize
and get started on tasks. 2) Attend to details and avoid excessive distractibility 3) Regulate alertness and
processing speed 4) Sustain and, when necessary, shift focus 5) Use short-term working memory and
access recall 6) Sustain motivation to work 7) Manage emotions appropriately [1].
In routine life, this cluster of cognitive functions synchronizes, often without our conscious involvement,
in integrated and dynamic ways to complete a wide variety of tasks. They don’t work continuously at peak
for any of us; everyone faces difficulty with any of them at any instance of time. However, those diagnosed

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with ADD are substantially more impaired in their ability to use these executive functions than are most
other people of the same age and developmental level [1].
The six executive functions that work together in various combinations are Activation - organizing,
prioritizing, and activating for work. Focus: focusing, sustaining and shifting attention to tasks. Efforts:
regulating alertness and sustaining effort and processing speed. Emotion: managing frustration and
modulating emotions. Memory: using working memory and accessing recall. Action: monitoring and self-
regulating action [1].
Because normal development of executive functions is not complete until late adolescence or early
adulthood, it is not always possible to identify, during childhood, students with impairments in these
functions. Some students do not manifest their ADD impairments in noticeable ways until they encounter
the more demanding world of high school, where they may be unable to cope with the ongoing conflicts
and demands of study, classroom performance, homework in several subjects, and family and social
interactions. Other students with ADD do not have noticeable symptoms until even later. Their parents
may have built such successful compensatory safety net around them that their ADD impairments do not
become apparent until the support system is suddenly removed-as when the student moves away from
home to attend a college or university: medications for ADD may help alleviate symptoms, but only for
those hours of the day when the medication is active in the brain. During these times, some students under
treatment can perform most self-management tasks quite well. For others, medication alone is not
sufficient [1-2].
ADHD starts in early childhood but ~ 20% cases are reported to persist in adulthood [2]. Adult ADHD
remains under reported/ under diagnosed, for lack of suspicion of its existence in adulthood [2-3].
Research suggests that the symptoms of ADHD can persist into adulthood, having a significant impact on
the relationships, careers, and even the personal safety of patients who may suffer from it [4-7]. Because
this disorder is often misunderstood, many people who have it do not receive appropriate treatment and,
as a result, may never reach their full potential. Part of the problem is that it can be difficult to diagnose,
particularly in adults.
To screen this disorder in any population, the Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom
Checklist was developed in conjunction with the World Health Organization (WHO), and the Workgroup
on Adult ADHD. The Symptom Checklist is an instrument consisting of the eighteen DSM-IV-TR criteria.
Six of the eighteen questions were found to be the most predictive of symptoms consistent with ADHD.
These six questions are the basis for the ASRS v1. Insights gained through this screening may suggest the
need for a more in-depth clinician interview. The checklist takes about 5 minutes to complete and can
provide information that is critical to supplement the diagnostic process. In routine various risk factors are
assessed to evaluate impulsivity, cognitive impairment, hyperactivity, learning problems, attentional
problems and oppositional conduct [8].
This study was undertaken to find out the prevalence of Adult ADHD in medical and paramedical
students and to study the association of certain variables with Adult ADHD.

METHODOLOGY

Design wise it is a cross sectional analytical study. Study was conducted over a period of 2 years (2013-
2014) in the campus of RD Gaardi Medical College, Ujjain which is a part of central India. Based on
qualitative research formula for sample size calculation (4PQ/L 2) sample size was estimated at 353.
Inclusion criteria for study population included 353 medical students belonging to MBBS, Physiotherapy
and Nursing courses of either gender and > 18 yrs of age who consented for the study. Patients found to be
positive on ASRS scale (as screening tool with sensitivity of 68.7% and specificity of 99.5%) 8 for ADHD
were interviewed in detail by neuropsychiatrist and were diagnosed as ADHD according to DSM-IV-TR
criteria. Predesigned & pre tested semi structured questionnaire was used as probe to reveal relevant
information regarding variables under study.
Variables under study like socio-demographic data and details of illness were recorded, pooled, tabulated
and subjected to statistical analysis.

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STATISTICAL ANALYSIS

Measures of mean & standard deviation for continuous data and Chi square test for qualitative variables
were used as statistical methods. Study was conducted after taking clearance from institutional ethical
committee. Verbal consent was taken from participants and confidentiality of data was maintained.

RESULTS

Socio demographic details

Study sample was N=353 belonging to MBBS, Physiotherapy (BPTh) and Nursing courses. Calculated
mean age of the patients = 20.05 (± 2.17) years. Course wise distribution of students was MBBS – 272
(77%), BPTh – 56 (16%) and Nursing – 25 (7%). Total participating males were – 176 (49.9%) and females
were 177 (50.1%). Total participants belonging to rural area were - 91 (26%) & urban area– 262 (74%). The
prevalence of ADHD in the study group was found to be 15.9% (56 out of 353 patients). The most
common type of ADHD found in the study population was - Inattentive type (50%) – 28 out of 56,
followed by Hyperactive type(18%) – 10 out of 56, Combined type (32%) – 18 out of 56. Among the
diagnosed 56 students with Adult ADHD characteristics, 59% were males and 41% were females.
In our study prevalence of Adult ADHD in medical students was found to be more in males (18.8%) than
females (13%, p value 0.139), urban areas (16%) than rural areas (15.4%, p value 0.884. As recorded in the
study the prevalence of ADHD was maximum in the age group of 18-20 years, about 21% in the 18 year
age group and minimum of 11% in the 25 year old ones, students older than 25 years did not report
ADHD symptoms. Prevalence of Adult ADHD was maximum in MBBS students (18.8%), followed by
the Physiotherapy students (8.9%, p value 0.015, statistically significant), No Nursing student reported of
ADHD symptoms. Level of education was found to be a statistically significant factor in association with
occurrence of ADHD in adulthood. However those who had h/o rash driving, frequent road accidents,
frequent quarrels, learning disabilities & substance abuse in school, those who had other co morbid
psychiatric complaints were not found to be significantly associated with ADHD in this study. Age &
gender were also found to be non-significantly associated.

DISCUSSION

The prevalence of ADHD in the study group was found to be 15.9% (56 out of 353 patients). The
prevalence seems to be almost equal to that in children and much greater than those reported from studies
by Fayyad et al. (0.8 – 1%) [9], Tuttle et al. (5.5%) [10] and Weyandtt et al. (7%) [11]. Data regarding
prevalence of adult ADHD/ adult onset ADHD are conflicting with respect to populations, geographical
areas etc. The estimated adult prevalence rate ranges between 3-5%. A study in Italy, New Zealand and
the US found prevalence rates of adult ADHD between 0-8.1% among student populations [3]. Another
study found that 7% of college students suffered significant ADHD symptoms, and suggested a role of
these symptoms in causing problems in academic and other important areas of functioning [12]. In an
anonymous survey of medical students in the US, 5.5% reported having been diagnosed with ADHD, with
72.2% of these having been diagnosed after the age of 18 years [13].

Clinical implications of the study

Prevalence of ADHD in adults (medical students in our study) seems to be greater than usually reported.
Students having ADHD are at risk of comorbid psychiatric problems like depression, learning problems
and accidents [6]. It thus becomes a worthwhile measure to screen medical students for ADHD and treat
wherever required and necessary. As such shtick grows old after the initial fervor so try to unravel the
tangled web with available contemporary validated medical tools in their formative years.
Several major self- and clinician-rated scales are currently available to assess whether an adult meets the
DSM-IV-TR criteria necessary for a diagnosis of ADHD. Certain examples of available tools are
Continuous performance test, Brown ADD scale, Working memory index, Processing speed index,
Barkley’s current behavior scale. These are either self-reported type or clinically administered [14].

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Table No.1: Distribution of various socio-demographic and disease related variables in association with
prevalence of ADHD in the study population

S.No Risk factors ADHD ADHD Total Chi-square value p-value

Present Absent (100%)
1. Age 8.280 (df=2) 0.688
>18-20 yrs. 44(18.33%) 196(81.67%) 240 (NS)
20-25 yrs. 12(11.21%) 95(88.78%) 107
>25 yrs. 0 6(100%) 6
Total 56 (15.86%) 297 (84.14%) 353
2. Gender 2.190 (df=1) 0.139
Male 33(18.76%) 143 (81.24%) 176 (NS)
Female 23 (12.99%) 154 (87.01%) 177
Total 56 (15.86%) 297 (84.14%) 353
3. Education 8.429 (df=1) 0.015(S)
M.B.B.S 51(18.8%) 221 (81.2%) 272
Physiotherapy 5 (8.9%) 51 (91.1%) 56
Nursing 0 25(100%) 25
Total 56 (15.86%) 297 (84.14%) 353
4. H/O Rash 2.641 (df=1) 0.267(NS)
driving 90
Yes 19(21.1%) 71 (78.9%)
No 37 (14.1%) 226 (85.9%) 263
5. H/O Frequent 1.768 (df=1) P=0.184
accidents 106 (NS)
Yes 21(19.8%) 85 (80.2%)
No 35 (14.2%) 212 (85.8%) 247
6. H/O Quarrels 0.030 (df=1) P=0.863
Yes 18(16.4%) 92 (83.6%) 110 (NS)

No 38 (15.6%) 205 (84.4%) 243

7. H/O Learning 3.542 (df=1) 0.060 (NS)

difficulties at
school
Yes 31(20%) 124 (80%) 155
No 25 (12.6%) 173 (87.4%) 198
8. Co-morbid 4.258 (df=1) 0.513 (NS)
disorders 345
No 54 (15.65%) 291 (84.34%)
Yes 2 (25%) 6 (75%) 8
Depression 2 (33.34%) 4 (66.66%) 6
Seizures 0 1(100%) 1(100%)
Phobias 0 1(100%) 1(100%)
9. H/O 0.755 (df=1) 0.385 (NS)
Substance use
Yes 65
8(12.3%) 57 (87.7%)
No 48 (16.7%) 240 (83.3%) 288

Note: H/O=History of, df=degree of freedom, ADHD=Attention Deficit Hyperkinetic Syndrome (in
adults), NS=Non-significant.

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While many individuals find their ADHD impairments becoming less problematic as they get older, due to
maturation of the brain or changing environmental demands, there are many for whom significant
impairment persists well into their adult years. Research has shown that many individuals with ADHD
find their functional impairments persist well into middle age and often beyond. In addition, bodily
changes may cause late onset of ADHD like impairments, e.g. for women during and after menopause,
and for both men and women as their bodies age. Extension of ADHD impairments into middle and later
years of life has not yet been adequately studied.
Accurately diagnosing ADHD is critically important. Missed diagnosis and the absence of treatment were
associated with educational, occupational, and social impairments in adaptive functioning, as well as an
increased risk of substance use disorder. Because of the high prevalence rate of ADHD, clinicians should
be aware of the symptoms and adult manifestations of ADHD and include screening in every adult
psychiatric evaluation [8, 13]. It was concluded that such studies should be undertaken frequently at
different geographical locations in different time frames to tackle this devastating problem in early stages.
Results of this study are indicating towards tip of the iceberg. So it is recommended to undertake such
studies at multicentre level with many other variables like verbal/reading abilities/audio verbal memory
assessment to explore the real magnitude of the problem in different age groups.

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Acknowledgements – We are thankful to Dr. Abhay Jain, Professor and Head – Dept. of Neuropsychiatry,
RD Gardi Medical College, Ujjain for his kind guidance and timely help in this research work
Conflict of Interest – Nil;
Funding – Nil.

Indian Journal of Mental Health 2018;5(2)