International Journal on ISSN 2077-3528

“Technical and Physical Problems of Engineering” IJTPE Journal

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March 2024 Issue 58 Volume 16 Number 1 Pages 299-306

ATTENTION DEFICIT HYPERACTIVITY DISORDER, COMBINED

SUBTYPE: PREVALENCE AND ASSOCIATED RISK FACTORS
H. Kesmat A.O.T. Ahami A. Khadmaoui
Laboratory of Biology and Health, Department of Biology, Faculty of Science, Ibn Tofail University, Kenitra, Morocco
kesmathamid@gmail.com, ahami_40@yahoo.fr, khadmaoui9@gmail.com

Abstract- Attention deficit hyperactivity disorder These three conditions are linked to a range of other
(ADHD) is a neurobehavioral disorder. Its core symptoms health problems that can impact patients’ mental,
are inattention, hyperactivity and impulsivity. There are linguistic, emotional and social development.
three subtypes of ADHD recognized by the DSM-5 Many questions are still unanswered, such as why more
manual Diagnostic and Statistical Manual of Mental children in certain countries are being diagnosed with
Disorders (DSM-5), classified by the predominant ADHD. These facts give rise to several questions in
symptoms: predominantly inattentive, predominantly medical and educational communities. Aside from
hyperactive-impulsive, and mixed subtype [1]. Our frequent academic struggles, young individuals can face
objective is to establish the frequency of ADHD combined behavioral problems (such as conduct disorders,
subtype. (ADHD-C) and to study the relationship between aggression and delinquency) as well as emotional
mixed type ADHD-C and socio-economic and cultural
difficulties (such as low self-esteem, anxiety and
factors in a population of secondary school pupils. Our
depression), which can have a severe negative impact on
study involved 119 pupils (63 boys and 54 girls), aged 12
their personal development and social interactions [2].
to 16, from the Sidi Yahia du Gharb city (North-West
Region of Morocco). Data were collected using a According to global guidelines, ADHD is regarded as
questionnaire extracted from the (DSM-5). The results of a genuine disorder and must be treated as such when its
this test show that the prevalence of children with ADHD- symptoms pose a disadvantage to the child and lead to
C in our sample was 10.08%. This neurobehavioral deficit sources of suffering in learning at school and/or social
was more frequent in boys (12.12%) than in girls (7.55%), relationships [3, 4]. In the last decade, numerous studies
with a ratio of 1.87. The prevalence of ADHD-C in school- focused on ADHD have improved our understanding of
aged children in northwest Morocco is comparable to other this syndrome. Studies involving brain imaging suggest
regions globally. This information is crucial for enhancing that individuals with ADHD exhibit differences in brain
the mental healthcare services available for assessing and structure. Other studies have revealed that ADHD has a
treating this form of ADHD-C. As such, it is crucial to significant genetic basis. Research has provided new
increase awareness of ADHD to guarantee that school insights into the effects of medication on the transmission
children receive suitable psychiatric care. of dopamine and noradrenaline [2].
This psychological disorder, which is the most
Keywords: Prevalence, ADHD, Children, ADHD prevalent among children is not a novel issue. The conduct
Combined Subtype, DSM5. and academic performance of a child or adolescent having
ADHD are frequently misapprehended by people around
1. INTRODUCTION them, which includes their family, school and society [5].
Difficulties in learning come in different forms and can The consequences of this disorder on the victim, as well as
be complex disorders. The most familiar types of learning those around him or her, the harm it does to the child’s
disabilities are dyslexia, dysgraphia, dyscalculia, future and its significant occurrence, all support its
dysphasia and dyspraxia. Another one is the attention
inclusion within public health priorities [6].
deficit disorder (ADD) with or without hyperactivity
Nonetheless, comprehending the diagnosis presents a
(ADHD). ADHD is a neurobiological condition that exists
difficulty for practitioners who have received inadequate
in all countries and among all ethnic groups and is
classified as a disorder or a syndrome. People with ADHD or no training on the disorder. They frequently face several
experience various problems involving their behavior, challenges in responding to queries from families,
such as difficulty concentrating, impulsivity and rendering assistance to affected children and giving
difficulties in social interaction. The major symptom of appropriate advice. Measuring the prevalence of ADHD
ADHD is attention deficit disorder, which is often universally remains a daunting task, but as per the (DSM-
associated with hyperactivity and impulsivity [1]. IV-TR.2000) by the American Psychiatric Association

Registered: 230715 Article Info: 1741 Accepted: 240224

Reserved: 230919 Available: 240331
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(APA), this disorder affects about 3 to 7% of school-going 2.3. Setting

children. According to Schiaretti, et al. (2013) [7], New Our research work deals with the problem of combined
Zealand, Germany and Brazil have also reported similar ADHD subtype and its impact on the learning of school
prevalence rates (Barkley, 2006). children in Morocco. In this country, the repercussions of
Prevalence rates in North America have varied this disorder on the patient and his or her entourage, the
between 2% to 26%, with variations depending on the negative impact on the child's future and its significant
author. According to Gonon (2010) [8]. North American frequency (around 10% of the general population), justify
authors most frequently use a 7% to 9% prevalence rate. its inclusion in the framework of public health priorities,
While in Canada, the rate is between 1 to 3 children per and require treatment, when the symptoms that
class, as mentioned by the Center for ADD/ADHD characterize it constitute a handicap for the child and
Advocacy, Canada (CADDAC) Montreal in 2010, and in therefore a source of suffering, whether in his or her
the United States, it affects 1 in 20 children (APA, 1994). schooling and/or social relations with the long-term risk of
However, the prevalence of ADHD-C depends on the deleterious repercussions on the whole of life (professional
diagnostic criteria used and the population studied, and is failure, social disintegration, additive behaviors).
comparable across different countries and cultures [9].
However, in Morocco, there are no official statistical data 2.4. Type of Study and Participants
available on the prevalence of this disorder. Our study, which was a horizontal, randomized
However, little research has investigated this matter
prospective study, involved 119 students (63 boys and 54
among children with ADHD in Morocco. The present
girls) who had not received any drug treatment, who had
study aimed to determine the prevalence of ADHD-C
symptoms in a specific group of teenagers (students of Ibn no somatic pathology, and follow their studies at middle
Yassin and Jaber Ibn Hayan secondary schools in the city schools in the city of Sidi Yahia Gharb in Morocco. The
of Sidi Yahia Gharb) in the northwest region of Morocco. study focused on school pupils aged six to twelve years
We aimed to identify potential factors linked to symptoms old. Proportional allocation was used to select an equal
of this subtype of ADHD and ascertain the correlation sample fraction of children in Table 1.
between ADHD-C and educational challenges.
Table 1. Distribution of students by school level
2. SUBJECTS AND METHODS Level Girls Boys Total
The 1st year of secondary school 20 43 43
2.1. Population The 2nd year of secondary school 17 25 42
The study was descriptive and cross-sectional i, aiming The 3rd year of secondary school 17 17 34
Total 54 65 119
to determine the prevalence of ADHD-C in the population.
among schoolchildren, along with the related risk factors.
The research was conducted at secondary schools located 2.5. Data Sources/Measurement
in the north-west, Morocco, during April and May, 2016. We asked an important question: how does having
This city is situated 67 km to the north of the capital, ADHD-C affect the mental abilities of young people, and
Rabat, and has a population of almost 27,030 residents. to what: extent is there a connection between having
The town is home to two government colleges that have a ADHD-C and encountering educational difficulties in a
combined student body of 3,000. The Institutional Review particular group of teenagers in Morocco.
Board of the Faculty of Science at Ibn Tofail University in This question represents the backbone of our research
Kenitra approved the study. and several guidelines emerge from it, namely:
• To investigate the prevalence of ADHD-C in a particular
2.2. Research Design cohort of students attending secondary school in the North-
The diagnosis of ADHD-C is presently founded on West Region of Morocco.
empirical criteria. defined in internationally recognized • Examines the correlation between this subtype and socio-
classifications (DSM5; ICD 10): the disorders cannot be economic and cultural factors in schoolchildren.
explained solely by the child's developmental age; they
must have begun before the age of 7, have lasted for more 2.6. Sampling Tool
than 6 months, and should be detected in at least two The diagnostic manual used for this purpose is the
different situations (e.g., school and home) with significant DSM-V. It provides a complete clinical description of
impairment in the child's social, academic and leisure various disorders.
behavior [10]. Similarly, questionnaires and evaluation - To establish this study, we distributed two questionnaires
scales (such as the famous "Conners scales") filled out by to the teachers working with these students, asking them to
the patient (adolescent or adult), his or her parents or read it carefully and fill in the appropriate boxes for each
teachers distinguish very well between groups (people question.
with combined ADHD subtype versus people without this - He hardly pays attention to details; he makes mistakes of
subtype), but for a given patient their reliability is inattention.
insufficient. In fact, the DSM is the most commonly used - He’s having trouble getting his attention.
medical tool for detecting ADHD [2]. In Canada, the US - There appears to be a lack of attentiveness when he is.
and other nations, the DSM-V criteria are used to assess a - They are not in accordance with instructions and do not
child's behavior and determine if the child has ADHD and perform tasks (without being in opposition). They have
which subtype [2]. difficulty planning and organizing their work or activities.

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- Avoids or reluctantly performs certain tasks, especially if socio-economic level, 35% (n=41) with an average socio-
they require sustained mental effort. economic level and only 6% (n=4) from wealthy families.
- He misplaces the items required for his work or activities. 7.6% (n=6) of the students surveyed had divorced parents
They are easily side-tracked by external distractions. and 95.8% (n=113) were women in households. According
- There is frequent forgetfulness in day-to-day life. to the number of years repeated, the distribution of
The affected individual must have at least six secondary students indicates that 26.9% (n=32) fail (one
symptoms of inattention repeatedly and to an unsuitable year repeated) and 4.2% (n=5) lose two years.
level, and incomparable with the normal level of Nevertheless, the distribution of the averages acquired in
development for age.
the first semester shows that 60% (n=71) of these pupils
had averaged between 10 and 15 of which 36.97% (n=44)
2.7. Statistical Tools and Variable
are male and 22.69% (n=27) are female, 29% (n=35) with
The data collected were entered on an Excel support,
averages between 5 and 10 compared to 9% (n=11) where
after filtration we transposed this matrix on an SPSS
the average displayed is less than 5/20 and only 2% (n=2)
(Statistical Package for the Social Sciences) support for a
of supposedly excellent pupils (score>1).
later analysis. Quantitative variables were expressed as
mean ± standard deviation and qualitative variables as
3.2. Behavioral History
frequency. Tests applied for the decision are: Khi-two test,
Table 3 shows the results of the antecedents of the
Pearson correlation and logistic regression, at an error of
pupils surveyed. In fact, 37.82% stated that they had a
5%.
history of ADHD. While 13.45% had no writing or reading
difficulties. However, 42.02% had anxiety disorders and
3. RESULTS
27.73% suffered from chronic illnesses. In addition,
21.85% said they had difficulty sleeping. However,
3.1. Characteristics of Study Population
89.08% said they consumed products high in sugar
The sample we gathered shows that the pupils' mean
(sweets). On the other hand, 47.06% did not eat breakfast
age is. 14.27±0.11 years, (min=11 years and a max=17
regularly. However, 33.61% of the pupils surveyed often
years). This distribution meets the requirements of
consult the internet and play video games.
Gaussian applications (asymmetry coefficient = -0.138
±0.222). 36.1% the school children (n=43) are in the first Table 3. Behavioral history of study population
year of college, 35.3% (n=42) in the second year and
29%(n=34) in the third year of college. The distribution of Behavior modality effective percent
No 74 62.18%
pupils according to their weight is shown in Table 2. History of ADHD
Yes 45 37.82%
44.5% (n=53) of these pupils have a weight between 40 Writing/reading Yes 16 13.45%
and 50 Kg, 25.2% (n=30) have a weight between 50 and difficulties No 103 86.55%
60 Kg and 30% (n=36) have a weight less than 40 Kg. The Fear and phobia
Yes 50 42.02%
Pearson correlation (0.421; p<0.000) revealed a strong link No 69 57.98%
Yes 3 2.52%
between age and weight. However, 98.3% (n=117) of Taking medication
No 116 97.48%
these children are born without any complications by Yes 33 27.73%
lower and 1.7% (n=2) of caesarean section. Chronic disease
No 86 72.27%
<8 80 67.23%
Number of hours of sleep
Table 2. Sociodemographic characteristics of study population (n=119) >8 39 32.77%
Yes 26 21.85%
Variable Modality N Percent Sleeping difficulties
No 93 78.15%
14.27±0.11 years (min=11 years Yes 106 89.08%
Age (mean±sd) 119
and a max=17 years) Consumption of sweets
No 13 10.92%
Boys 66 55.46%
Sex Yes 63 52.94%
Girls 53 44.54% Taking breakfast
No 56 47.06%
first year of secondary school
43 36.13% Near 99 83.19%
Educational (The 1st year) Source of pollution
Far 20 16.81%
level. The 2nd year of secondary school 42 35.29%
Internet and video game Yes 40 33.61%
The 3rd year of secondary school 34 28.57%
addiction No 79 66.39%
30-40 25 21.01%
40-50 53 44.54%
Weith (kg) 50-60 30 25.21% 3.3. Prevalence of ADHD
60-70 10 8.40% The prevalence of the ADHD-C in the town of Sidi
70-80 1 0.84% Yahia Gharb among school-age children was 10.08%,
Free function 89 7.79%
bearing in mind that the prevalence of student inattention
Parents' function Public function level 1 22 18.49%
Public function level 2 4 3.36% ADHD type is 9.24%, while prevalence of Hyperactivity-
No 82 68.91% impulsivity ADHD type is 6.72% in Table 4.
School failure
Yes 37 31.09%
SD: Standard Deviation Table 4. Prevalence of ADAH type of study population
ADHD type Total no. with disorder Prevalence
In addition, 83% (n=99) come from urban areas and Inattention 90.76% 9.24%
17% (n=20) only from rural areas. Nevertheless, 63% Hyperactivity-impulsivity 93.28% 6.72%
(n=74) of these pupils come from households with a low Combined 89.92% 10.08%

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3.4. Determining Factors of ADHD-C sleep difficulties (chi2=3.07; p<0.05): 15 out of 20.
Table 5 shows the results for the combined symptoms 18.91% of students showing signs of ADHD-C required 7
of intentional and hyperactive/impulsive deficits. The to 8 hours of sleep. However, 11.32% of children with this
prevalence of combined symptoms was 10.08%. This type of ADHD reported eating sugary foods. The analysis
disorder occurs more frequently in boys (12.12%) than in permitted the classification of intentionality
girls (7.55%). These excessive activities affect almost all hyperactive/impulsive children as those who possess a
school levels. These children generally have an average family history of this condition. Additionally, these
weight of between 50 and 60 kg. The chi2 test showed a children endure chronic conditions and dedicate extensive
significant association between combined ADHD and time engaging with online media and video game.

Table 5. Study of the link between socioeconomic and cultural factors and combined ADHD subtype (ADHD-c)
ADHD-C ADHD- C
Variable Modality Khi-Deux P-value Prevalence
Yes No
Boys 8 58 12.12%
Sex 0.68 0.41
Girls 4 49 7.55%
Free function 10 79 11.23%
Parents' function Public function level 1 1 21 1.79 0.41 4.54%
Public function level 2 1 3 25%
No 10 72 12.19%
School failure 1.30 0.05
Yes 2 35 5.40%
No 7 67 9.46%
History of ADHD 0.084 0.77
Yes 5 40 11.11%
Yes 7 43 14%
Fear and phobia 0.002 0.96
No 5 64 7.25%
Yes 0 3 0%
Taking medication 0.34 0.56
No 12 104 10.34%
Yes 3 30 9.09%
Chronic disease 0.05 0.82
No 9 77 10.46%
Yes 5 21 19.23%
Sleeping difficulties 3.07 0.05
No 7 86 7.53%
Yes 12 94 11.32%
Sweets consumption 1.64 0.20
No 0 13 0%
Taking breakfast Yes 6 57 9.52%
0.046 0.83
No 6 50 12%
Internet and video game Yes 5 35 12.5%
0.39 0.53
addiction No 7 72 8.86%
ADH-C: Combined ADHD subtype

4. DISCUSSION the UK [17], while other studies conducted in Asia [11],

The aim of this study was to determine the occurrence Africa [18], and Arab countries [11 , 19] appeared very
of ADHD-C symptoms in Moroccan schoolchildren., as comparable to these findings.
well as the risk factors likely associated. A cross-sectional However, in the United States, according to a national
descriptive study using simple random sampling selected survey of parents conducted from 2016 to 2019, millions
119 students aged 6 to 12, and 300 reports were obtained of children have been diagnosed with ADHD, with an
from teachers. The prevalence rates of the predominantly estimated number of 6 million (9.8%) children aged 3 to 17
inattentive type, the predominantly hyperactive type, and ever diagnosed with ADHD, this figure covers 3.3 million
the combined type were 9.24%, 6.72% and 10.08%, individuals, with 13% being children aged 12 to 17. Boys
respectively. These results are identical to studies in (13%) are diagnosed with ADHD more frequently than
Vietnam and Saudi Arabia [11]. On the other hand, girls (6%) [20]. In the same way, in our study, this ADHD-
according to the DSM-V criteria, these prevalence of C had a higher prevalence amongst boys compared to girls.
ADHD-C among schoolchildren is much higher than that This matches the results of a study done in the United
calculated in other countries. [11, 12]. States by the American Psychiatry Association [2] and in
The prevalence of schoolchildren diagnosed with Africa by Ayano, et al. (2020) [18]. Similar findings were
ADHD-C in our study was 10.08%, in line with rates found seen in multiple European studies, including Cortese et al.
in Europe [13], and Latin America by several studies [14, (2013) and Setyawan, et al. (2017) [21], as well as a
15]. So, according to previous studies, in Spain the previous study conducted in Riyadh, Saudi Arabia [19, 22].
prevalence of ADHD-C would be 3-14% in children aged According to this article, the data also demonstrated a
8-15 years in Valencia [13], 4-6% in children aged 6-15 significant correlation between the diagnosis's prevalence
years in Seville [23] and 1% in children aged 6-8 years in and socio-economic status. Similarly, Pillai, Patel, et al.
Navarre [16]. Similarly, Real, Bartoli et al (2017), reported (2008) [23]., and Russell et al (2016) [24], approved that
that the incidence of the combined subtype of ADHD-C in people from lower socioeconomic backgrounds have a
a sample of children in Europe was comparable across prevalence of 6.4%, those from middle levels have 5%, and
countries, and mean impairment scores for primary and those from higher levels have 3.2%. In this context we
secondary symptoms differed and were higher in Italy and found that children with ADHD-C whose parents work in

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lower-level jobs have a prevalence rate of 25%. In addition, difficulties and 15% to 35% of children diagnosed with
11.23% of the fathers of these children work in non-paid reading difficulties have this syndrome. In both cases,
activities and 12.12% live near a source of pollution [24]. attentional components may be affected at different levels.
In terms of genetic inheritance, ADHD-C affects both Psycho-educational support is therefore often essential
sexes and he is thought to be a highly heritable condition (Charlebois, 2000). It should be noted that these children
of neurodevelopmental origin [25]. In fact, 11.11% of the are frequently unable to succeed in school, or are at risk of
students with ADHD-C who participated in this survey struggling, despite generally possessing intellectual
reported that there was at least one family member who functioning that falls within or surpasses the norm [29].
also had ADHD-C, indicating that genetics contribute Another consequence of the disorder is that interpersonal
significantly to the development of ADHD. Research into relationships are often problematic, even leading to
identical twins has demonstrated that if one twin rejection by peers. In addition, these behavioral problems
experiences ADHD, there is an 80% likelihood that their in ADHD-C children often poison the teacher-child
co-twin will also be affected by the condition [17, 18]. In relationship. According to Gomes, Hilary, et al. (2012),
addition, in the majority of cases, at least one family these children have a number of weaknesses, poor selective
member has ADHD. Several genes associated with ADHD attention, difficulty in following a task, and a degree of
have been identified, but genetics alone cannot fully disorganization similar to the inattention found in ADHD
explain the condition [26]. without hyperactivity [30].
Comorbid disorders are often associated with ADHD, In addition, the differential diagnosis of children with
the most common being: oppositional defiant disorder, ADHD may also include mental, emotional, behavioral, or
sleep disorders, social and emotional problems, speech and conduct problems, depression disorders, autism spectrum
language disorders, bipolar or obsessive-compulsive disorders, central auditory disorders, dysphasia, drug
disorders, motor disorders and learning difficulties [20]. In addiction and anxiety disorders, as they can present as
a longitudinal study comprising 208 children diagnosed primary or secondary manifestations of ADHD-C. Figure
with ADHD, Dalsgaard et al (2001) found that learning 1 [20]. However, anxiety disorders affect 14% of children
difficulties were present in 60% of the children in their with ADHD, whereas 37.48% of children who are
sample. It should be emphasized that children whose considered hyperactive need 7 to 8 hours to get enough
ADHD is predominantly inattentive are significantly more sleep and 19.23% find it extremely difficult to sleep.
likely to have learning difficulties than children whose Nevertheless, M. Lemelin, T. Boukhris, et al. (2019) [31].
ADHD is predominantly hyperactive/impulsive or mixed. mention that 25% of children with ADHD also suffer from
[27]. In our research, out of 16 respondents who reported depression and/or anxiety. As pointed out by Maric,
having reading and writing difficulties, one student had Bexkens and Bogels, (2018), anxiety may be a protective
ADHD-C, and 25.56% of these students had at least factor for certain types of attentional tasks. The results
average grades. These findings are consistent with Miller, show that the ADHD children in the study who were
et al. (2001) research, [28] indicating that 25% to 40% of anxious seemed to be more attentive than the other children
children with ADHD-C received a diagnosis have reading in the study.

Figure 1. Percent of children with ADHD who had at least one other disorder [20]

The symptomatic triad (inattention/hyperactivity/ teaching-learning process among school children in school
impulsivity) may also reflect family, environmental and systems [32].
medical problems. In terms of health, 9.09% of the Ultimately, the increase in the prevalence of ADHD-C
ADHD-C students had a chronic illness, and none of the may affect children's social life and success at school, and
ill students confirmed the use of tranquillizers or a we need to make families aware of this condition so that it
treatment designed for this purpose. In addition, 12.5% of can be diagnosed and treated early. The study possesses
the ADHD-C students showed a very strong attachment to several constraints that could influence the interpretation
the use of the Internet and video. This addiction of video of findings. [19] Firstly, a larger study population would
games and the Internet can be offset by the introduction of
provide more meaningful results.
information and communication technology (ICTE) in the

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47, No. 3, pp. 440-458, 2016. Name: Ahmed
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University of Grenoble, Academy of Grenoble, France Name: Abderrazak

1980 Surname: Khadmaoui
DEA: Clinical Psychology, Claude Bernard University. Birthday: 17.09.1965
Lyon I, Academy of Lyon, France 1981 Birthplace: Bni Mellal, Morocco
Doctorate: Ph.D. in Clinical Psychopathology, Bachelor: Immunology, Department of
Department of Biology, Lyon II University, Lyon Biology, Faculty of Science, Kaddi Ayad
Academy, France, 1984 - Ph.D. in Human Biology and University, Marrakech, Morocco, 1990
Neuroscience, Claude Bernard University, Academy of DEA: Genetic and Molecular Biology, Department of
Lyon, France, 1986 Biology, Faculty of Science, Tunis 1992
The Last Scientific Position: Prof., University PES: Department of Biology, Faculty of Science, Ibn
Psychologist / Neuropsychologist and Biology, Tofail University, Kenitra, Morocco, 1997
Laboratory of Biology and Health, Department of Last Scientific Position: Prof., Genetic Statistics and
Biology, Faculty of Science, Ibn Tofail University, Molecular Biology, Laboratory of Biology and Health,
Kenitra, Morocco, 1991 Department of Biology, Faculty of Science, Ibn Tofail
Research Interests: ADHD, School Mental Health, and University, Kenitra, Morocco, Since 1997
School Performance Research Interests: Genetic, Biostatistics Epidemiology
Scientific Publications: 320 Papers, 212 Communications, Scientific Publications: 32 Papers, 18 Communications, 2
3 Theses Theses

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